The Co-operative Commonwealth Federation, Health Care Refom and Physician Remuneration in the Province of Saskatchewan, 19 15- 1949
A Thesis
Submitted to the Faculty of Graduate Studies and Research
In Partial Fulfillment of the Requirements
for the Degree of
Master of Arts
In Politicai Science
University of Regina
by
Gordon Stewart Lawson
Regina, Saskatchewan
March, 1998
Copyright 1998: G. S. Lawson National Library Bibliothèque nationale 1+1 ofCanada du Canada Acquisitions and Acquisitions et Bibliographie Services seMces bibliographiques 395 Weilington Street 395, rue Wellington OüawaON K1AONQ OrtawadN KtAW Canada Canada
The author has granted a non- L'auteur a accordé une licence non exclusive licence allowing the exclusive permettant à la National Libmy of Canada to Bibliothèque nationale du Canada de reproduce, loan, distribute or sell reproduire, prêter, distribuer ou copies of this thesis in microfom, vendre des copies de cette thèse sous paper or electronic formats. la forme de microfiche/film, de reproduction sur papier ou sur format électronique.
The author retains ownership of the L'auteur conserve la propriété du copyright in this thesis. Neither the droit d'auteur qui protège cette thèse. thesis nor substantial extracts fkom it Ni la thèse ni des extraits substantiels may be printed or othemise de celle-ci ne doivent être imprimés reproduced without the author's ou autrement reproduits sans son permission. autorisation. ABSTRACT
This thesis examines the origins and development of medical care
insurance in the province of Saskatchewan with respect to physician remuneration from 1915 to 1949. In particular it seeks to determine why the Co-operative Commonwealth Federation(CCF) government of TI C.
Douglas did not follow the recommendations of its Health Services
Planning Commission(HSPC) for the establishment of a state salaried medical service based on the province's extensive systern of municipally employed salaried physicians. Its purpose is to provide a clearer understanding of how and why fee-for-service payment became entrenched
in Saskatchewan, the birthplace of Canada's national medical care system.
The decision of the Douglas government not to implement the 1945
HSPC proposals for a salaried general practitioner service was made in the context of an alleged Saskatchewan CCF party cornmitment to salary remuneration and support for salaried medicine from the province's municipal doctors. This thesis assesses the validity of the various hypotheses and explanations in the established historical accounts of this policy decision and weighs them against empirical evidence. The evidence includes previously unstudied prirnary sources from the
Saskatchewan Archives Board and the Archives of the Saskatchewan
Medical Association and the College of Physician and Surgeons of
Saskatchewan.
It is concluded that the CCF did not establish a salaried medical service in Saskatchewan as reconnnended in the 1945 HSPC proposals because: neither the party or the government was committed to salary remuneration; the policy of the Douglas government was to provide medical services to the people of Saskatchewan as rapidly as possible with the CO-operation of organized medicine; and the medical profession, including the province's salaried municipal doctors, was fervently opposed to being placed on salary. This thesis is the product of several years of extensive archiva1 research. It is a pleasure to acknowledge those who aided me in this undertaking. I am especially indebted to the Saskatchewan ~edical
Association and the College of ~hysiciansand Surgeons of saskatchewan for access to their archives; to Dr. Briane Scharfstein, Executive
Director, and the staff of the Saskatchewan Medical Association for their assistance and the generous use of their photocopier; to the
Provincial Archivist of Saskatchewan, Trevor Powell, and the staff of the Saskatchewan Archives Board in Regina and Saskatoon for their assistance and for grdnting permission to examine several restricted collections; and to Lisa A. Mix of the Allan Mason Chesney Medical
Archives, Johns Hopkins Medical Institutions. 1 also would like to thank the Honourable Allan Blakeney, former Premier and Minister of
Health of the Province of Saskatchewan, who introduced me to Dr. C.
Stuart Houston, medical historian and former Head of the Department of
Medical Imaging at the University of Saskatchewan. Dr. Houston granted permission to use the papers of his father, Dr. C. J. Houston, as well as brought to my attention several articles that were useful in my research. Rosa Morgan invited me to the 1995 Seniorst University Group
Inc. Distinguished Canadian Award Dinner where 1 met both Mr. Blakeney and Dr. Houston. In addition, several friends opened up their homes to me for which I am most grateful: Gordon Shaffer, Ottawa; Robert Norris,
Saskatoon; and Robert Bjerke and Tady Clarke, Saskatoon.
The travel and research were made possible by a generous first year Masters Hannah scholarship from the Hannah Institute for the
History of Medicine/Associated Medical Services Incorporated for which
1 was a privileged recipient in 1995-1996. 1 also wish to acknowledge
iii an enhancernent award from the Faculty of Graduate studies and ~esearch,
University of Regina, as a result of receiving a Hannah scholarship.
Further funding for my studies was provided by the Department of
Political Science, University of Regina, in the form of teaching assistantships. 1 would also like to thank Dr. Kenneth A. Rasmussen,
Faculty of Administration, for employment as research assistant.
1 especially want to thank my advisor Dr. ~aymondSentes for his guidance, patience and support during the course of the development of this thesis. 1 wish also to express my appreciation to Dr. Howard
Leeson and Professor Gerald Sperling for scrutinizing a late draft of this thesis.
1 would like to take this opportunity to thank Dr. Joeseph
Roberts for supporting a presentation of rny Masters research at the
Young Scholars Session of the Society for Socialist Studies, Annual
Meetings, June 7-10, 1997, Congxess of the Learned Societies, St John's
Newfoundland. 1 wish also to thank both Dr. Roberts and Dr. Phillip
Hansen for their instruction, guidance and encouragement during my studies at the University of Regina. This thesis evolved out of a research paper that 1 wrote fox a course on the Politics of
Saskatchewan offered by Dr. Lorne A. Brown, who has been particularly appreciative of my work on the history of socialized medicine in
Saskatchewan.
1 would also like to thank Car10 and Christine Binda for their friendship and support during the, at times frustrating, writing and editing process.
And, finally, 1 wish to express my sincere gratitude to my parents, Demis and Patricia Lawson, for their financial support, understanding and unfailing encouragement throughout my studies at the
University of Regina. Table of Contents
Chapter 1 INTRODUCTION
Endnotes
Chapter 2 MüNICIPAL CONTRACT PRACTICE & PHYSICIAN REMUNERATION IN THE PROVINCE OF SASKATCHEWAN: 1915-1 945
Introduction Saskatchewan's Municipal Doctor System Private Practitioners and Municipal Contract Practice Municipal Doctors and the SCPS Endnotes
Chapter 3: THE POLITICS OF HEALTH CARE REFORM IN 1940's SASKATCHEWAN: HEALTH INSURANCE VERSUS STATE MEDICINE
Introduction State Medicine, Health Insurance and Socialized Medicine Organized Medicine and the State Hospital and Medical League The Select Special Cornmittee on Social Security and Heaith Services and the Saskatchewan Reconstruction Council: State Medicine or Health hsurance? Health Services Survey Commission Endnotes
Chapter4: THECCF,HENRYSIGERISTANDPHYSICIAN REMUNERATION POLICY IN SASKATCHEWAN: 1937-1945
Introduction The CCF Health Care Policy and the 1944 Provincial Election: Salary or Fee-For-Service? Preparation for Salaried State Medicine? The Old Age Pensionen Scbeme The Heaith Senices Survey Commission: September 6- October 5, 1944 Report of the Comrnissioner, Henry E. Sigerist The Establishment of the Health Services Planning Commission Endnotes Chapter 5: THE RWECTION OF THE 1945 HSPC SALARIED MEDICAL SERVICE PROPOSALS AND THE DEVELOPMENT OF MEDICAL CARE SERVICES IN SASKATCHEWAN: 1945- 1949
Introduction 1945 Health SeMces Planning Commission Rural Health Care Proposais Meeting of the Advisory Committee to the Hedth Services Planning Commission, March 2-3, 1945 Meeting of the Central Health Insurance Committee and TC. Douglas, March 2 1, 1945 Municipal Contract Practice: April22,1944 - November 3,1945 The Swift Current Medical Care Program and Physician Remuneration in Saskatchewan: 1946 - 1949 Endnotes
Chapter 6: CONCLUSION
Endnotes
Bibliography CHAPTER 1
INTRODUCTION
The Saskatchewan Co-operative Commonwealth Federation(CCF1 government of 1944-1964 is recognized for its profouad influence on the development of Canada's medical care insurance system, commonly
referred to as Medicare. As the first provincial government to provide
compxehensive, universal coverage for medical services, the CCF proved
the feasibility of a nation-wide medical insurance scheme, and both prepared public opinion and formulated the political demands that led
to the implementation of medicare by the Federal government in 1966-
Moreover, the Saskatchewan Medical Care Insurance Plan served as the mode1 for the national medicare programme.
This instrumental role of the CCF in the evolution of Canadian medicare, coupled with the ferocity and high drama of the doctors'
strike in 1962, has overshadowed interpretations by many historians
that the medical insurance plan implemented in Saskatchewan in 1962 was not what the CCF had intended or advocated when it came to power in
1944. In his classic study of the Saskatchewan CCF, Agrarian
Social i Sm : The Co -opera tive Commonweal th Federati on in Saska tchewan , S.
M. Lipset States that the "Party leaders originally envisaged a medical system in which al1 doctors would work on a salaried basis ...."' Frequently based on Lipsetts work, subsequent accounts of the evolution of health insurance in Saskatchewan and Canada often cite a
Saskatchewan CCF cornmitment to a salaried medical service.' For example, C. David Naylor in Private Practice and Public Payment:
Canadian Medicine and the Politics of Xealth Insurance, 1911-1966 notes the following : The party's avowed intention of setting up a saiaried state medical service womed the SCPS[Saskatchewan Coiiege of Physicians and Surgeons] which, from the 1930s on, had endorsed oniy "state-aided Health insurance on a reasonable fec-for-sdce basis.~'
There are historians who make no reference to a CCF resolve to replace
fee-for-service(ffs) payment with the salary method, but these accounts
do not challenge the general assertion found within the works of
Lipset, Naylor and other scholars.'
The 1962 doctorsf strike has also overshadowed what existing historical accounts of the step-by-step development of medical care insurance in Saskatchewan from 1944 - 1962 indicate was a less dramatic, but equally formative, conflict concerning physician
remuneration in 1945.' Indeed, at a glance, it would appear that the
CCE may have initially sought to implement a state salaried medical
scheme when it came to power in 1944.
Stan Rands, for example, notes in Policy and Privilege: A History
Of Community Clinics In Saskatchewan, 'after the election of 1944, some of the early actions of the new CCE government seemed to indicate that
radical policies could be e~pected."~First, the CCF appointed an
internationally renowned expert on the Soviet health care system and a
staunch advocate of salary remuneration, Dr. Henry E. Sigerist of Johns
Hopkins University, to chair a survey of health care semices in
Saskatchewan. His report, submitted October 4, 1944, recommended
salary remuneration.' Then in eaxly 1945, the CCP government's Health
Services Planning Cornmission(HSPC), a small group of professionals personally selected by the Premier and Minister of Public Health, T. C.
Douglas, devised a medical services plan for rural Saskatchewan that
envisaged the expansion and development of the province's municipal
doctor system into a salaried general practitioner service. This plan was in turn presented to, and considered by, the HSPC Advisory Committee, comprised of representatives of organized medicine and the general public, on March 2, 1945. These initiatives may have seemed like the first phase of a strategy to implement a state salaried medical service in Saskatchewan. However, a survey of existing scholarship indicates that within a year of unveiling the 1945 HSPC pxoposals, the government had clearly relinquished any plans it may have had to establish a provincial medical care plan with payment for physician services on a salary basis.
Organized medicine was adamantly opposed to the establishment of a state salaried medical service. SCPS representatives confronted the
Premier at a private meeting March 21, 1945, registering their objections to the HSPC proposals. Existing accounts maintain that
Premier Douglas and the Cabinet considered implementing the HSPC proposed salaried medical care scheme in the face of the strong opposition of the medical professionla but in subsequent negotiations with the doctors during 1945 Douglas, in Naylor8s words, "gave way" to the medical profes~ion.~Jacalyn Duffin and Leslie A. Falk in "Sigerist in Saskatchewan: The Ouest for Balance in Social and Technical
Medicine," quoting Mindel C. Sheps of the HSPC Planning Commission, write:
The HSPC issued a memorandurn in favour of centralized government control and physician payment by salary, but the College of Physicians objected and, after "delay and temporizing,lf she wrote, "that[issue] was settled just the way the doctors wanted it...in the direction we didn't want them to go." 'O
According to Malcolm G. Taylor in Healeh Insurance and Canadian Public
Policy: The Seven Decisions that Created The Canadian Heal th Insurance
System, the 1945 HSPC proposals and the attendant friction constituted the CCF government8s 18first confrontationn with the medical prof ession. l1 Hiatorians agree that the CCF government of TOW Douglas did net follow the 1945 HSPC recommendations for the establishment of a salaried medical service in rural Saskatchewan.12 Two health policy initiatives undertaken by the CCF in 1945-1946 are identified as indicating the government1s rejection of the HSPC proposals. First, following negotiations with the Saskatchewan College of ~hysiciansand
Surgeons(SCPS) during the Spring and Sumrner of 1945, Premier Douglas sent a lettsr to the SCPS that historians of Saskatchewan medicare tend to agree precluded the establishment of a state salaried medical service.13 According to Douglast widely-quoted letter of September 19,
1945, the SCPS would have "unrestricted jurisdiction over al1 scientific, technical and professional mattersw and would be able to determine "the general character of the agreement and arrangements whereunder the profession will provide medical services."" Naylor notes that with this letter "Douglas had clearly abandoned the partyts cornitment to a salaried medical service under department of health auspices. lr15 Similaxly, Malcolm G. Taylor states that with this letter,
SCPS official Dr. Lloyd Brown "happily observed that the new govemment now stood for health insurance rather than [salariedj state medicine."l6
Second, in early 1946, in the Swift Current Health Region, the first of several health regions organized in the province during the
CCF's fixst term in office, the provincial government assisted the regional health board in setting up a medical services plan for its
50,000 residents. Physicians were paid on a ffs basis.17
This thesis explores the apparent transformation of CCF health tare policy during the Douglas government s first term in office (1944-
1948). In particular, it seeks to determine why the CCF government of
Tommy Douglas did not follow the HSPC recommendations for a salaried medical scheme. The significance of this policy decision in the
evolution of public health insurance in Canada was succinctly
articulated by Malcolm G. Taylor:
What if Premier Douglas had acted on the advice of his Health Planning Commission to iatroduce a medical care program, with general practitioners paid by salary.... Had that policy option been ixnplemented, it is obvious that, in some parts of Canada, at least, the design of the delivery system might weil have been vastly different."
Indeed, some contemporary scholars maintain that the CCF concessions to
organized medicine in 1945-1946 led to and entrenched ffs payment in
Canada's medical care system.19 For example, Katherine Fierlbeck in
"Canadian Health Care Reform and the Politics of Decentralization"
writes :
While the original Saskatchewan blueprint for public health care envisioned salaried doctors, the medical organizationç refused to sanction the scherne unless they maintained their professional autonomy through a fee-for-service system. Physicians in Canada are thus essentially private contractors rather than state employees....'O
Despite its importance, this crucial decision and the conf lict over physician remuneration in 1945 has been discussed only in passing by historians Canadian medicare .
Historians of fer three interpretations about the CCF did not
follow the 1945 HSPC recommendations for a salaried medical service in
rural Saskatchewan. The first is that organized medicine's opposition
and their threat that the HSPC salaxied medical scheme would compel doctors ta leave Saskatchewan and deter others from coming to the province induced the Douglas government to reject the HSPC proposals.
For example, Malcolm G. Taylor States:
As the Premier and the Cabinet weighed the situation and assessed the opposition of the College, it was concluded that the over-riding concern was the severe shortage of physicians in Saskatchewan, augmented by the warnings of the College that the introduction of a systern as radical as that proposed by the commission would not ody deter many doctors fiom coming but cause othm to leave. This thrcat appears to have been the dominating factor afféctmg many of the Goverment's decisions?' Lipset Socialism adds :
The Saskatchewan governent was faced with the possibility that the socialization of medicine would cause a large number of doctors to leave the province. Members of the govemment feared that they would then be blamed for the consequent decline in medical standards and services."
Second, David C. Naylor Priva te Practice, Public maintains that Premier Douglasf 'concern was to impiement programs of health services as amicably and rapidly as possible."" Naylor suggestç that this factor, coupled with SCPS opposition and its threat that the
HSPC plan would both cause doctors leave and discourage immigration, exacerbating the province's existing doctor shortage, led to Premier
Douglas' concessions to the medical profession in 1945.~~
A third interpretation is offered by Lipset in Agrarian
Socialism. Lipset suggests that the HSPC proposals were not implemented because the people of Saskatchewan did not desire a state salaried medical service. Lipset argued that the HSPC proposals were not implemented because a) the electorate did not understand or demand qualitative changes in medical care, and b) there was a lack of organized pressure groups that supported qualitative changes:
The Saskatchewan govenunent, however, is not backed by an electorate that understands or demands qualitative changes in medical care. The people wanted greater and cheaper quantities of the kind of sentice they already had. The farmers supported "statew medicine, but to them the tenn meant state payrnent of medical care, fiee medicines, fkee hospitalization, prepayment of medical costs, and medical care of pensioners and indigents...-The pressures of groups opposing social change mut be counterbalanced by other powerfbl groups. The lack of major groups in Saskatchewan opposing the well- organized medical profession has been a large factor in the success of that group."
Lipset concluded:
Thus, govemment officiais are factd on one hand with the popular demand for any kind of state medicine on the one hand, and, on the other, with the threat of sabotage by physicians unless the plan of their organized profession is put into practice. The compromise of the basic goals of reforrn of medical practice naturaiîy fo~lowed.~~ This thesis will test the aforementioned interpretations in the established historical accounts the Commonwealth
Federation and the development of medicare in Saskatchewan.
In order to accurately assess physician opposition to the HSPC proposals, Chapter 2 of the thesis examines the Saskatchewan medical profession's position regarding physician remuneration, with a particular emphasis on the municipal doctor system. Malcolm G.
Taylor's account of the Premier's pivota1 meeting with the SCPS negotiating March suggests that the province ' s salaried municipal doctors were not opposed to the HSPC proposals.
Taylor intimates that the municipal doctor representative on the negotiating committee, Dr. R. K. Johnston, was not against a salaried system in rural Saskatchewan:
The committee accepted subsidy of doctors in remote areas, but opposed grants which could or might be used 'as a means of coercion to force a salaried system of medicaI care in rural areas.,' There was one discordant voice in the Coliege delegation, that of Dr. R. K. Johnston, a municipal doctor. He reported, as chairman of the Municipal Doctor Cornmittee, that in a survey he had conducted, seventy-one municipal doctors "were almost 100 percent for a practice consisting of municipal contract work[salary] and outside practicelfees for major surgery], and that on the whole they favoured the municipal work as it was now operated." But his voice was lost in the committee cormnitted, as it was, to fee-for-service." (note. brackets by Taylor)
Dr. C. Stuart Houston, in contrast, states in the Canadian Medical
Association Journal that the HSPC plan "at once alienated the salaried municipal doctors, for it would deny them any right to private practice or to attend any one from beyond a rigid area bo~ndary."'~
According to Lipset, in 1944, the residents of 101 of 303 rural municipalities, 60 villages and 11 toms with a combined population of
200,000 people received medical services from municipal doctors working on a salaried basi~.'~In view of the extent of salaried medical practice in Saskatchewan in the 19408s, officia1 SCPS opposition may have been less of an obstacle to the establishment of a salaried medical scheme than existing scholarship suggests, and may even have been surmountable. Hence, a study of the medical professionts opposition to the HSPC proposals must include careful consideration of the views of the municipal doctors.
Were the province's municipal doctors, as a review of the available literature suggests, entirely removed from private medical practice with the exception of the major surgery they provided on a ffs ba~is?~'Did the municipal doctor prefer salary remuneration over ffs payment? Finally, were the municipal doctors favourable to a salaried medical scheme as proposed by the HSPC in 1945?
SCPS policy towards physician remuneration is also explored in this second Chapter. Taylor states that the wCommission[HSPC] members, and presumably, the premier, were unprepared for the imrnediate and negative response from the College" to the 1945 HSPC proposals for the establishment of a state salaried medical service.31 This was because a
SCPS brief of March 1943 concerning a post-war medical services plan stated that 'We think the scheme can be combined with something equivalent to the Municipal Doctor Plan, with payment on a combined salary and fee ba~is."~'What exactly did the SCPS mean by this statement? What precisely was SCPS policy towards salary remuneration and the municipal doctor system? Chapter 2 attempts to answer these questions through an analysis of SCPS records, files of the Health
Services Board (a tripartite medical, rural municipality, and provincial government body set up to regulate the municipal doctor system) , as well as the Saskatchewan Medical Quarterly, the journal of the Saskatchewan College of Physicians and Surgeons. The hypothesis put forward by Taylor and others that physician opposition caused the
CCP government to reject the 1945 HSPC salaried medicine proposals is then assessed. Chapter 3 provides an account and analysis of the submissions to three government-appointed inquiries into health services in 1943-1944.
The purpose of this third chapter is to explore Lipset's interpretation that the Douglas government did not follow the 1945 HSPC recornmendations because it was not backed by an electorate that supported the establishment of a state salaried medical service.
In order to test Lipsetts hypothesis, Chapter 3 attempts to determine the nature and extent of public support for a salaried medical scheme before the CCF came to power in 1944. To this end, the medical cale policy positions of various lay organizations are examined. Special emphasis is placed on the Saskatchewan ~ssociationof Rural
Municipalities (SU), in Taylor's words, 'one of Saskatchewanls most poweriul political iorces, representing as it did 302 rural m~nicipalities";~'and the State Hospital and Medical League(SHML1.
According to Taylor, the SHMZ was a confederation of voluntary and govemmental organizations including homemakers clubs, fraternal societies, church and farm organizations, the Saskatchewan Teachers
Federation, CO-operative groups, 120 rural municipalities, six cities, twenty-four toms and fifty-six villages." Naylor States that bath the
SHML and SARM supported the CCF salary remuneration p~licy.~'These endorsements may suggest that there was significant public support for the establishment of a salaried medical service in Saskatchewan during the 1940ts.
Chapter 3 also clarifies how the different lay organizations, political parties, and the medical profession understood the various terminologies in common usage in Saskatchewan for pre-paid medical services plans. These terms include "state medicine," "socialized medicine" and "health insurance." A review of the available literature suggests that the general public. political parties and the doctors defined and utilized these terms differently. For example, Lipset states that the farming community supported state medicine, but to them the term meant free medical services,36 rather than a state salaried medical service, as was understood by the medical profession and the HSPC .
Chapter 4 begins with a xeview of CCF health care policy from the
1937 until the party assumed office in 1944, with the objective of both determining and clarifying the nature of the party's commitment to salary remuneration. Lipset was the fixst to ascribe such a cornmitment to the CCF health reform plans. In Agrarian Socialism, he cites the
"Handbook to the Saskatchewan CCF Platform and Policy," issued in 1937, to illustrate a CCF cornmitment to salaried medicine:
The physicians favored health insurance under which they would continue to prachce exactly as they did under private medicine, except that they would send theù bills to the state instead of to the patients. The CCF, however, has long rnaintained that health insurance was no solution to the problem of adequate medical care. A pamphlet issued by the party in 1937 makes this position clear."
Stan Rands, in Privilege and Policy, also cites the 1937 CCF policy booklet:
This document declares that there is a great need for state or socialized medicine, that the health needs of the people will not be met by simple arranging for payment while the present system of practice continues, and that if we are to have prevention as weii as treatment, the state must necessady assume comol. This statement desit clear that the provincial party at the tirne saw medical insurance as inadequate, and sought an overaU policy administered by a health plan with the professionais, including physicians, on salary.'"
Donald Swartz also contends that such a commitment was reiterated in the party's 1944 election platform in which historians agree the party pledged to introduce Nsocialized rnedi~ine."'~ For example, he states in "The Politics of Reform: Public Health Insurance In Canadaff that :
The CCF had never advocatcd hcalth insurance; the party's program called for "socialized medicine," which included salaricd physicians working in publicly owned clinics and hospitals with some measures of popular contr01.'~ Rands argues further, in support of his contention that the CCF promised to implement a salaried medical service during the 1944 provincial election, that the "party program [19441 declared in categorical terms that no insurance scheme can do the job."41
However, McLeod and McLeodls account of Tommy Douglas as Minister of Public Health in Tommy Douglas: The Road to Jerusalem suggests that, as the 1944 Saskatchewan provincial election approached, the CCF leadership was not irrevocably committed to salary remuneration.
According to McLeod and McLeod, the CCF executive of Tomrny Douglas and
Clarence Fines "agreed in 1943 to the outlines of a rnedicare system ...."" But the -question of whether doctors should work on salary or receive a fee fox each service provided was left open."43
Did the CCF assume office in 1944 undecided in terms of how physicians ought to be paid in a province-wide pre-paid medical care scheme? Was the CCF as cornrnitted to a salaried medical scheme as many scholars contend? How exactly did the CCF define "socialized medicine" prior to and during the 1944 provincial election? CCF policy documents from the late 1930's up until and during the 1944 election are examined in Chapter 4 in order to answer these questions.
After xeviewing the health care policies of the CCF party,
Chapter 4 proceeds to provide an historical account, and an accompanying analysis, of the Douglas government's health care initiatives up until the unveiling of the HSPC salaried medical scheme.
The controversial appointment of Dr. Sigerist to the Health Services
Survey ~omrnission(HSSC)is examined, as well as his final report. The negotiations of the CCF governmentls medical care plan for old age pensioners and other social assistance beneficiaries is also explored, and the significance of the government's acceptance of ffs payments is discussed. Throughout thie period the pronouncements of Premier Douglas and government officials are examined to determine the CCF government's health care policy. Was the CCF government of T. C.
Douglas planning and preparing to implement a state salaried medical service?
Chapter begins with a description the HSPC proposals , with an ernphasis on how the CCF health planners envisaged the implementation of a salaried medical service. This is followed by an account the March meeting of the HSPC advisory committee.
Did the lay representatives on the HSPC advisory committee support the
HSPC recommendations for a salaried medical service? The SCPSI meetings with the government are then revisited, from the Premier's initial confrontation with the SCPS negotiating committee March 21,
1945, until Douglas1 widely-quoted letter of September 19, 1945. This examination will test Naylor's interpretation about why the HSPC recornmendations for the establishment state salaried medical service were not implemented. Naylor mites:
By this time the SCPS had already recogaized one important fact: T. C. Douglas was a politician - not a planner. As such, his concern was to implement programs of health services as arnicably and rapidly as possible. Leaders of the college repeatedly bypassed the HSPC and members of bis staff to ncgotiate with Douglas directly, thereby winaing a variety of concessions. Given the province's chronic shortage of doctors, a point of special concern to Douglas was the SCPS'S warning that sweeping changes in the provincial health care system rnight drive practitioners out of Saskatchewan and discourage immigration. The extent to which Douglas gave way is indicated in a letter dated 19 September 1945....U
The establishment of the Swift Current Medicare Care Plan is then explored to detemine how it came about that ifs remuneration was instituted in this experimental medical care plan. Public reaction to this departure from the 1945 HSPC proposals is detailed as a further test of Lipset's contention that the Saskatchewan electoxate did not support the establishment of a salaried medical service.
In addition, the CCF efforts to improve and expand the municipal doctor system via financial grants are examined. According to Duane Mombourquette in -An Inalienable Right: The CCF And Rapid Health Care
Reform, 1944-1948" the SCPS supported this initiative:
The HSPC's proposals for salaried doctors working in nual health centres met with strong condemnation fÎom the medical profession .... the ColIege wanted medical practice based on a fee-for-service method of payment not Local Health Centres with saiaried positions.... Faced with this strong opposition ...the government shifted the thnist of its efforts to improving the municipal doctor system. This had been advocated as an appropriate fmt step by Sigerist and also had the approval of the ColIege of Physicians and Surgeons and the old Health Services ~oard.''
MacLeod and MacLeod, in contrast, state that the SCPS was opposed to the expansion of the municipal doctor system:
Henry Sigerist had written that the municipal doctor plans, a form of local medicare, aiready formed "the backbone of al1 medical services in the provincen in 1944, and he recommended that the plans be extended and developed. The College of Physicians and Surgeons opposed the idea and by putting pressure on its members, made it almost impossible for them to pursue careers as municipal doctors on ~afary.'~
The possibility is explored that this initiative was the first step in a CCF strategy to introduce a salaried scheme at a later date.
Chapter 6 presents a concluding assessrnent of the various hypotheses set out in Chapter 1. It attempts to provide a comprehensive explanation of why the CCF did not establish a salaried medical service in rural Saskatchewan as recommended in the 1945 HSPC proposals. Endnotes:
1 Seymour Martin Lipset, Agrarian Socialism: meCo-operative Commonwealth in Saskatchewan (Berkley: University of California Press, 1950), p. 288.
2 Donald Swartz, "The Politics of Refonn: Public Health Insurance In Canada," International Journal of Health Semes, Vol. 23, No. 2 (1993), p. 225; Stan Rands, "The CCF in Saskatchewan" in Donald C. Kerr ed. Western Canadian Politics: The Radical Tradition (Edmonton: NeWest Press, 1981), p. 61; Stan Rands, Pnvilege And Policy: A History of Contrnuniîy Clinics in Saskatchewan (Saskatoon: Cornmunity Health Co-operative Federation, 1995), p. 98; Aleck Ostry, "Prelude to Medicare: Institutional Change and Continuity in Saskatchewan, 1944-1962," Prairie Fonrni, Vol. 30, No. 1 (Spring, 1995), pp. 101- 103.
3 David C. Naylor, Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911-1966 (Kingston and Montreal: McGili-Queens University Press, 1986), p. 136.
' Malcolm G. Taylor, for example, is silent on this issue.
5 Malcolm G. Taylor, Health Insurance and Canadian Public Policy: The Seven Decisions that Created neCanadian Health Insurance System (Montreal: McGiii-Queen's University Press, 1978), pp. 245-250; Naylor, pp. 139-142; Lipset, p. 293.
Rands, Privilege And Policy, p. 99.
' Ibid; Jacalyn DSin and Leslie A. Falk, "Sigerist in Saskatchewan: The Quest for Balance in Social and Technical Medicine," Bulletin of the History ofMedicine, 70, (1996), p. 675.
8 Taylor, p. 248.
' Naylor, p. 140.
'O Dufiand Fak, p. 666.
1 I Taylor, pp. 245-250. t 2 Lipset, p. 293; Taylor, pp. 248-250; Naylor, pp. 140-14 1. t 3 Taylor, p. 250; Naylor, pp. 140-14 1.
14 Taylor, pp. 249-250.
I S Naylor, p. 141.
16 Taylor, p. 250.
17 Naylor, p. 142; Lipset, p. 293.
18 Taylor, p. 417.
19 G. Gray, Federalism and Health Policy (Toronto: University of Toronto Press, 1991), p. 35. -- ---
'O Kathcrine Fierlbeck, "Canadian HeaSth Care Refom and the Politics of Decen~tion,"in Christa Altenstetter and James Wamer Bjorkmau ed. Health Policy Refiorm, National Variations and Globaiization (London, United Kingdom: Macmillan Press Ltd, 1997), p. 26.
*' Taylor, p. 248.
22 Lipset, p. 296.
23 Naylor, p. 140.
24 Ibid.
" Lipset, p. 297.
26 Ibid.
27 Taylor, p. 246.
28 C. Stuart Houston, "The early years of the Saskatchewan Medical Quarterly," Canadian Medical Association Journal, Vol. 118 (May, 1978), pp. 1127- 1128.
" Lipset, pp. 288.
30 Naylor, p. 163; Taylor, pp. 246-247.
3 1 Taylor, p. 245.
" Ibid.
33 Taylor, pp. 84-85.
34 Ibid., pp. 85-86.
3s Naylor, p. 136.
36 Lipset, p. 297.
37 Ibid., p. 289.
3 8 Rands, Privilege And Policy, p. 98. j9 Rands, "The CCF in Saskatchewan," p. 61.
40 Swartz, p. 225.
4 I Rands, "The CCF in Saskatchewan," p. 61.
42 Thomas H. McLeod and Ian McLeod, Tommy Douglas: 77te Rmd to Jemalem (Edmonton: Hurtig Publisbers, 1987), p. 148.
43 Ibid.
44 Naylor, p. 140. " Duane Mombourquette, "An halienable Right: The CCF And Rapid Heaih Care Reform, 1944-1948," Saskatchewan Hisrory, Vol. 43, No. 3 (199l), pp. 105-106.
" McLeod and McLeod, p. 150. MUNICIPAL CONTRACT PRACTICE & PHYSICIAN REMUNERATION IN THE PROVINCE OF SASKATCHEWAN: 1915- 1945
Introduction
When the CCF came to power in Saskatchewan in 1944, a substantial number of the province's physicians were already remunerated on a salaried basis. According to a "Medical Manpower Survey" of the province of Saskatchewan conducted by the Canadian Army Medical
Corps(CAMC) during the Second World War, in 1943, of the 408 practising physicians in Saskatchewan, 130(31.7%) were on full-time salaries and
63(15.3) were on part-time salary. As noted by the authors of the report, 'this unusually high proportion of salaried physicians" was
"due ta the widespread adoption in the rural areas of the municipal doctor scheme."' Indeed, by the early 1940's more than a half of the province's rural-based general practitioners were essentially salaried employees of the governing bodies of rural municipalities, villages and toms. It was through an extension and development of this indigenous medical care system that the Douglas government's Health Services
Planning Commission(HSPC) envisaged the establishment of a salaried general practitioner service in rural Saskatchewan.
This chapter seeks to determine if indeed the municipal doctor system, and in particular the municipal physician, was as conducive to the establishment of a salaried state medical service in Saskatchewan as it would appear, particularly in terms of physician support for such a project. The first section of this chapter provides a brief description of the municipal doctor system, with a particular emphasis on the scheme's private practice element. A second section consists of an account and analysis of physician opinion and SCPS/SMA policy
towards the municipal doctor system and physician remuneration in general . The findings will be used to address the particular questions
concerning the municipal doctor system set forth in Chapter 1. Were
the municipal doctors entirely removed from private practice with the
exception of major surgery rendered on a ffs basis? Did the municipal
doctor prefer salary remuneration over the ffs method? Were the municipal doctors favourable towards a salaried medical scheme along
the lines of the HSPC proposals? What exactly was organized medicine's position on municipal contract practice and salary remuneration in a provincial medical services plan?
Saskatchewan's Municipal Doctor System
As Joan Feather notes in "Early Medical Care in Saskatchewan," in
the early 1900's:
Fee-for-service practice was the mainstay of prairie medicine but it could only attract a physician where there were enough patients to support a practice and where patients could afford to pay the doctor's fets. Unforhuiately, these conditions could not be met in al1 rural areas.7
The limitations of fis remuneration gave rise to Saskatchewanfs
salaried municipal doctor system in rural Saskatchewan between 1915 and
1930.' As the system expanded during the 19301s, the scherne was adopted
in areas where private practice was still viable, including some of the most densely populated and prosperous farm regions in the province.'
By 1943, one year before the CCF came to power in Saskatchewan, the residents of 106 rural municipalities or parts of rural m~nicipalities,~65 villages and 8 toms received general medical
services, including minor surgery and maternity care, from municipal doctors. These 179 cornmunities had a combined population of 204,788 persons, 22.8% of entire 1941 population of 895,992 persons and approximately 32% of the rural population. Nine of the 106 rural municipalities with medical care schemes remunerated physicians on a ffs basis. The remaining 97 agreements with rural municipal councils and al1 of the 73 contracts with villages and toms paid participating physicians a straight salary for general practitioner service^.^ In
1943, seventeen of these agreements permitted the doctor to collect deterrent fees of $1.00 to $3.00 for initial house calls (two doctors were allowed to charge $10.00); ten included fees ranging frorn $3.00 to
$7.00 for maternity cases; four permitted fees of $2.00 to $5.00 for fractures; and four agreements "allow the doctor a fee from the patient for certain other services."' Sixty-three of 179 rural municipalities, villages and toms with municipal medical care plans also provided coverage for major surgical procedures; twenty-nine suxgical contracts were on ffs ba~is.~
According to the 1943 CAMC survey these schemes involved
113 (salaried) doctors, j ust over a half of the province ' s 213 rural - based general practiti~ners.~Seventy-three were on a full-time basis, with a contract with one or more rural municipalities. Forty physicians were on a part-tirne basis, with a contract with a part of a municipality, village or town. ln 1941 the populations of the villages with municipal doctors plans ranged from 56 to 466 persons, with an average of 192 persons; the populations of the 5 toms with municipal medical schemes ranged from 387 to 1033 persons, with an average of 509 persons.1° Accordingly, most town and village municipal doctor contracts would therefore not be considered full-time appointrnents. Part-time municipal doctors are best considered private practitioners with salaried contracts. At a glance the 1945 HSPC proposals for the establishment of a
state salaried medical senrice in rural Saskatchewan, modelled as they
were on the existing municipal doctor system, appear as a continuation
of the status quo for the province's full-time municipal physicians,
with the exception that they would no longer be paid for major surgery
on a ifs basis. This perception ignores the important but
unacknowledged fact that, from the scheme's inception, the majority of
full-time municipal doctors engaged in extensive private practice.
That practice consisted of both general medical care and major surgery,
in addition to the surgical care they provided to the residents of
their contracting municipality on a private ifs basis. The municipal
doctors xeferred to this private income as "outside practice."ll
This additional private income was derived from two sources.
First, al1 contracts with rural municipalities permitted private practice in the villages and toms situated within its geographical boundaries.12 Second, municipal physicians both accepted cases from,
and engaged in private practice, outside the borders of the contracting municipality. This was despite the fact that many of the plans established after 1937 were based on a mode1 agreement (circa 1936-
1937),13 introduced by the Health Services Board(HSB)," stipulating that
the municipal doctor was:
To give his whole time and attention as a practising physician to the service of the Municipaliry during such employment and not to practise his profession outside of the Municipality or with respect to patients outside of the Municipality, except in some case of emergency... . l5 The mode1 agreement also prohibited the collection of extra fees for house calls, maternity cases and minor surgery, with the exception of unnecessary calls to the home for which the doctor was allowed to collect $2 and a mileage charge? The municipal doctors were opposed to this restriction on their private practice privileges, and in the early 1940's sought to have it
eliminated via a new model contract devised by Dr. J. J- Collins, a
salaried municipal doctor, that strengthened and enhanced the scheme's
private practice provisions." Accordingly, the HSB and the Department
of Health were informed that the "the physician should be allowed to
practise in territory adjacent to the municipality without prejudice.""
A special committee of the SCPS met with the provincial government and
the HSB several times in late 1942 and early 1943 to discuss Dr.
Collin's model contract, which had been approved by the College May 20,
1942.19 The Deputy Minister of Health, Dr. Davidson, was 'to draft a
clause including the changes that would meet with the approval of both
organizations . However, it was not until the CCF came to power that the aforementioned restriction on private practice was eliminated. In
the interim, this restriction appears to have had a marginal impact on
the municipal doctorst private income- Dr. Collin's 1941 report calling for the removal of this impediment to the municipal doctors' private practice activities suggests that this restriction was neithex adhered to by the majority of municipal doctors, nor enforced by municipal councils .'l
Clearly some municipal doctors' earnings consisted almost entirely of their salary contracts. Municipal physicians in localities surrounded by other physicians on contract, and who did not perform major surgery or did 80 on a salary basis appear to have been completely removed from private medical practice. For example, in
1937, the municipal doctor for the rural municipality of Sarnia, whose contract of $4000 included three villages and provisions for major surgery reported to the HSB that he had "practically no private patients as 1 am surrounded by municipal doctors. And 1 do major ope ration^,"'^ However, for many municipal doctors a substantial portion of their income was derived from private medical practice, as a
SCPS survey undertaken in 1944 indicates.
At the SCPS Annual General Meeting September 18-20, 1944, Dr. R.
K. Johnston, a salaried municipal doctor, reported that of the 71 physicians who replied to a questionnaire he had drafted and sent to al1 the municipal doctors in the province, 69 stated that they supplemented their salaries with private practice on a ifs basis.
Johnstonls survey also dernonstrated that 70 of the 71 doctors would not be content if their incomes were restricted to their present salary. A majority of these same physicians were satisfied with their present income, i.e. municipal contract plus private practice." This suggests that ffs practice was quite substantial.
According to an earlier survey conducted by Dr. J. J. Collins in
the average municipal doctor s gross income was earned pri~ately.'~ One may presume that as the rural economy improved during the war, the average municipal doctor's income increased.
The monetary value of some municipal doctorsl private practices appears to have exceeded their municipal contracts. For example, in a submission to the 1944 Sigerist Commission, the rural rnunicipality of
Tisdale stated that the private earnings of its municipal doctor in
1939 surpassed the remuneration of his salary of $4000.00 per annum:
We might also add that in addition to having rendered the above services to ou.residents, we believe we are sufficicntly well-infomcd to state that this doctor also rendcrcd services to patrons under pnvate practice htwould give him more than equat that of his contract? In this context the municipal doctor cannot be equated to a salaried civil servant as envisaged in a state salaried medical setvice. The proceedings of the Saskatchewan Legislaturets Special Select Cornmittee on Health and Welfare(1943-1944) underscores this fact: Wewe recognize there are many disadvantagcs, which are due to the economic conditions prevailing in the districts, would you say these mai (Municipal Doctors] are in the category of civil servants?
Dr. Gareau [SCPS]:
Defmtely not. Also, municipal doctors have to do a lot of private practice. Othe-e good men wouldn't stay in those districts. As far as your municipal scheme is concemed, we are aii for if but think it could be imp~oved*~ The extent and magnitude of this private practice must be considered in examining municipal doctor opinion towards contract practice and other medical services schemes, particularly a system that entailed the placing of general practitioners on a straight salary with no private practice privileges.
Pnvate Practitioners and Municipal Contract Practice
Private physicians appear to have been opposed the municipal contract practice from its inception. During his surveys of the municipal doctor scheme during the summers of 1929-1930, C. Rufus Rorem observed that :
Private physicians in Saskatchewan on the whole express disapproval of the system, but allege that in rurai areas it may be the only way to assure the continued presence of a medical practi tioner ." However, as the municipal doctor scheme expanded during the 1930's to densely-populated and prosperous areas where private medical practice was still economically viable, organized medicine sought to both restrict and eliminate municipal contract practice. At the
Twenty-seventh Annual Meeting of the Saskatchewan Medical Association
(SMA), August 20, 1934, President G. H. Lee declared in his address to the assembled physicians that:
This system should be reserved for providing medical services for those co~~~munities,and those only, in which, because of local conditions, medical scrviccs could not well be provided in any other way. Such conditions would bc where settlement is very sparse, and the amount of work doue would not assure a practitioucr of an adequatc living on any othcr bais of remuuerati~n.'~ Dr. Lee went on to suggest that "perhaps the solution [to municipal contract practice] could be found in a system of State Health
Insurance.
The utility of a province-wide health insurance scheme as a means of eliminating municipal contract practice was first brought to the professionts attention in early 1933 by the SMA Special Cornmittee on
Health Insurance, chaired by Dr. S. E, Moore, a private practitioner.
At a Special General Meeting, February 28, 1933, Dr. Moore presented his committeefs recommendation and proposa1 for the establishment of province-wide health insurance scheme on a ffs basis as an alternative to the municipal doctor system." In a supplement to the report, concerning the municipal doctor question, the Special Committee noted that: 'if the Health Insurance Plan was adopted then there would be no cal1 or requirement for or engaging of any particular one as municipal physician.. . .n3L
In the months ahead, the Special Committeets recommendation that the SMA approach and obtain the support of the provincial government and various lay organizations in the province for the establishment of a compulsory, contributory health insurance scheme on a ffs basis was endorsed by the profession. Less than a year earlier, the Council of the SMA had rejected the concept of a province-wide health insurance scheme, blaming Canadian Medical Association officiais for the public's interest in state health insurance, or "state medicine" as it was often referred to in the early 1930's.~' It would appear that opposition to an expanding municipal doctor scheme contributed to this policy shift.
The elimination of the municipal doctor system also appears to have been the impetus behind SCPS support for a provincial obstetrics plan put forward by Dr. F. H. Coppock of Rosthern at the 1935 SMA/SCPS Annual Meeting, September 24-25, 1935. Dr. Coppock. a rural-based
private practitioner. was a staunch opponent of the municipal doctor
system.'3 His proposa1 called for the rural and urban municipalities to
jointly finance al1 maternity cases in the province. One of the
benefits cited by Dr. Coppock for such a medical care scheme was:
nearly every Mimicipal Doctor would receive sufficient remuneration fiom this obstetric service to enable him to tear up his contract and continue to practice in the sa.disîrict without being subjected to dictation, intefierence, or unfair dismissal."
Noting that it "would help solve the Municipal Doctor question,D35the
SMA/SCPS Joint Special Legislative Cornmittee endorsed Dr. Coppock's
maternity grants scheme at a Cornittee meeting January 15th. 1936."
Dr. Coppock's plan was presented to various lay organisations and the
provincial government, but like the 1933 SMA health insurance proposal.
it would appear that the provincial government was unwilling to provide
the necessary financing." The lack of government support most likely
befell the Regina District Medical Society(D.M.S.)1938
resolution(approved by the majority of physicians in attendance at the
1938 SCPS annual meeting)and subsequent proposa1 calling for the
replacement of the municipal doctor system with a ffs contributory
health insurance scheme in rural Saskatchewan, financed jointly by the
Municipal. Provincial and Federal ~overnments.~"
In 1939 the members of the Regina D.M.S. also established the
first doctor-controlled medical insuxance plan in Saskatchewan. In
response to efforts of a group of ~eginacitizens to establish a medical CO-operative staffed by physicians on ~alary.'~but also fearing that the medical nprofession as a whole may of necessity become ...the servants of groups of lay-people and municipal b~dies,"'~the Regina
D.M.S. set up Medical Insurance Incorporated(MS1). Modelled after Dr.
J. A. Hannahts Toronto-based Associated Medical ~ervices," M.S.I. remunerated physicians on a ffs basis, and offered its lay membership choice of doctor. M.S.I. restricted its operations to Regina in its inaugural year, but the Regina D.M.S. aspired to extend the scheme into rural saskatchewan .42
To this end, the SCPS successfully lobbied the provincial government to amend, in early 1940, the Municipalities Act to allow municipal councils to engage the services of physicians on a fis basis." As well, the Municipal Medical and Hospital Services Act was amended to permit groups of physicians, such as M.S.I., to enter into rnedical services agreements with muni~ipalities.~~Although M.S.I. did not enter into any agreement with a rural municipality for general practitioner services until after the CCF had came to power in 1944, the aforementioned amendments permitted the establishment of municipal doctor plans on a ffs basis. Indeed, in his 1941 report to the SCPS on the municipal doctor system, the president of M.S.1, Dr. Lloyd Brown recommended that municipal physicians obtain ffs con tract^.^^ By May of
1944, 10 rural municipalities were paying their doctors on a ifs basis for general practitioner services.46
This Regina D.M.S. initiative coincided with the 1941 survey mentioned previously by Dr. J. J. Collins, a salaried municipal doctor, concerning physician opinion towards the municipal doctor systern, health insurance, and "state medicine," which the SCPS defined as a medical care system in which al1 physicians would be salaried civil servants. Concerning private practitioner opinion of the municipal doctor system, Dr. Collins reported that "the non-contract doctors were in general averse to Municipal me di ci ne.^'^ However, his survey also indicated significant support for salaried state medicine among the province's private practitioners, albeit exclusiveïy among rural-based physicians: What systcm of practice is the choice of the physician?.... The Ru.Doctorsrnvate practitionm]also favoured private practice although many of the older men expresscd preference for State Medicine and the younga men for Hdth Iiisuiance. In the case of the Municipal Doctors, pnvate practice secmcd to bc the type of practice of choice, but Municipal and State Medicine had many followers and Health ïnsurpnce a few. Of the Rural Doctors a large percentage favoured State or Municipal Medicine, wbile neither of these systems found one supporter in the Urban cend8 In terms of what medical care system was rnost suitable to Saskatchewan according to medical opinion, Dr. Collins stated:
in the Rural centres the doctors were reasonably unanimous in declaring private practice to be no longer feasible and in the case of the Municipal Doctors they were unanimous in this regard. The Mimifipal Doctors kiieved the Municipal system to be most suitable while the men in private practice believed State Medicint to be the most suitable wiîh Health Inmrance and Municipal Medicine having their sponsors. In summarizing we may Say that where private practice is no longer feasible, then, for Urban centres, Health humnce is the most suitable system while for Rural localities Municipal or State Medicine is to be prefemd to Health insurance. This is the consensus of opinion of the doctors intimately acquainted with their temtory." These responses may suggest that rural-based private practitioner support for state medicine was to a large degree, contingent upon whether or not private medical practice was feasible.
Officia1 SCPS policy with respect to state medicine, health insurance and municipal contract practice and, in turn, physician remuneration within a provincial medical services plan in post-war
Saskatchewan took shape in the early 1940's beginning at meeting March
18, 1942, called specifically ta deal with these issues .'O The physicians in attendance re-affirmed SCPS support for "state-aided health insuxance on a reasonable fee-for-service-rendered ba~is."~' In doing so, the SCPS simultaneously rejected a scheme of salaried state medicine for the province.
This initiative was motivated by a presentation, on the eve of
March 18, 1942, to the Regina D.M.S. by the Secretary of the Canadian
Medical Association, Dr. Routley, on the contributory health insurance proposals of the federal Department of Pensions and National Health.
Developed in close consultation with CMA of fi ci al^,'^ the federal draft legislation envisioned a health insurance programme financed by
individual premiums, employer contributions and government subsidy. In
terms of physician remuneration, doctors would be paid by salary,
capitation, ffs or a combination thereof, as determined by the
"Provincial Cornmi~sion.~~~Dr. Routley encouragea the SCPS to
officially endorse contributory health insurance as envisioned in the
forthcoming federal proposals.
As recommended by the Regina D.M.S., the Council of the SCPS set up a "commîttee on health insurance," initially comprised entirely of private practitioners, to study the federal proposals and prepare SCPS policy with respect to the implementation of the federal scheme in
~askatchewan.~' Accordingly, the health insurance committee set to work preparing an officia1 remuneration policy. In the interim, however, the SCPS submitted a brief to the Saskatchewan Legislature's Select
Special Cornmittee on Social Security and Health Services that contained a position on payment of doctors.
As Malcolm G. Taylor notes in Health Insurance and Canadian
Public Policy the SCPS brief stated that:
While we are fïrmiy of the opinion that any schcme of health insurance should in general provide for the patient a fÏee cboice of his medical attendant whcre practicable, and services should be paid for on a reasonable and agreed fee for services rendered basis, we do think the schtme can be combined with something equivalent to the prcsent Municipal Doctor plan, with payment on a combined salary and fee-for-service basis." Nevertheless, salary remuneration for general practitioner services was only acceptable to the SCPS leadership in sparcely settled areas with a population insufficient to maintain a doctor on a ffs basis:
Point 15 of the Canadian Medical Association health insurance principles attached hercto provides that the contract-salary sewice bc iimitcd to artas with a population insufficient to maintain a general practitioner without additional support fiom the insurance fùnd." Strict adherence to such a policy would entai1 the dismantlement of the salaried municipal doctor system and the re-introduction of ffs in the densely-populated and more prosperous rural areas, as a Liberal member of the Select Special Committee pointed out to the SCPS delegation:
Dr. Danielson (Likral):
In Saskatchewan a large number of municipalities place the medical doctor on salary and yet they are some of the most advanced districts in the Province. Would you suggest that be done away with and have it only in places where poor roads are and in far-out districts? 1 thhic we have 100 municipalities in the Province that are in the hospitaiization schemes. 1 know in my own district that there are some doing that and it is just as progressive a part of the province as any. Would it be your suggestion that the municipalities wouId discontinue that practice and go in on a "pay" or "feet*basis?
Dr. Gareau (SCPS):
Weil, we have not any definite decision on that, That is something that wodd have to be worked out? Dr. Danielson's query and Dr. Gareau's evasive response reflected the popularity of the salaried municipal doctor system in rural
Saskatchewan.
During the surnrner of 1943 the SCPS "Central Health Insurance
Cornmittee" completed and sent to al1 members of the medical profession two resolutions with respect to physician remuneration in provincial health insurance scheme. The first resolution called for fis remuneration, and combined salary/ffs "contract arrangements similar to present Municipal Doctor schemes" in areas of the province where ffs payment alone was not viable.'' A second called for the "Capitation
System[to] be eliminated entirely from any Health Scheme in
Saskatchewan. M59
This resolution was re-submitted to the Health Insurance
Committee for further study after the SCPS General Meeting, September
16-17, 1943, "refused to deal with the res~lution."~~The Health
Insurance Cornmittee, in turn, after failing to arrive at an agreement at a meeting January 30, 1944, appointed a subcommittee on remuneration to consider the re~olution.~~In addition, the subcommittee was to draft a response to a request from the governrnent-appointed Saskatchewan
Reconstruction Council(SRC)for a "clear statement of where the College stands on the question of methods of rern~neration."~' The SCPS had previously submitted its brief to the Saskatchewan Legislature's Select
Special Committee on Social Security and Health Services to the SRC with a note that since its pxesentation "we have seen no reason to change Our ~iews."~~The SRC noted that the CMA in its brief to the
Federal government-appointed Advisory Committee on Health Insurance, chaired by John J. Heagerty, stated its "acceptance, in principle, of both fee-for-service and capitation fee methods of payment, not even going dei inetly (sic) in favor (sic)of the former. . . ."64 The SCPS was asked if a "panel system, or even payment by salary, be more acceptable, if adequate provision were made for leave of absence for post-graduate and research ~ork."~'
It is worth rnentioning here that at the SCPS annual meeting of
September 1943, Dr. C. J. Houston of Yorkton presented a ffs contributory health insurance scheme to the Central Health Insurance
Committee that he devised together with Dr. R. A. Dick of Canora(a1so a pxivate practitioner). Like the earlier sMA/sCPS and Regina D.M.S. proposals, this medical care plan envisaged the discontinuation of salaried municipal doctor practice. In thinly-populated areas where ffs alone could not provide a physician with an adequate income, instead of municipal contract, doctors would be paid a subsidy to supplement their ffs earning~.~~
The remuneration subcommittee recommended ffs for both urban and rural Saskatchewan, with municipal contract as an 'alternative planN in rural areas, noting that "Under present conditions, these two plans are frequently combined-even those doetors on contract supplement their earnings by fee-for-servi~e."~' The subcomittee considered this recommendation to be a rejection of the capitation method.='
A minimum salary of $6000 was recommended for municipal doctors for general practitioner services, with services exceeding this amount to be paid on a ffs basis. The committee suggested that surgery rendered by municipal physicians be on a ffs basis."
Aithough the remuneration committee indicated a preference for ffs outside of "sparsely settled and remote areas" where only the salary method would "retain a medical man,"" unlike the SCPS brief to the Select Special Committee on Social Security and Health Senrices, it did not explicitly recommend that salary remuneration be confined to areas "with a population insufficient to maintain a general practitioner without additional support £rom the insurance fwd,"" as set forth in the CMA principles on Health Insurance.
The remuneration subcomittee recommendations were oificially approved by the SCPS as part of the conclusions of the Central Health
Insurance Cornmittee," at its 1944 annual meeting September 18-20,
1944.'' In the interim, they were submitted to the SRC along with the following reply to a query concerning the SCPS views towards the formation of group practice clinics:
fn Saskatchewan there is the municipal system of doctors, which is giving an excellent service, and if "the gaps are filledw and if adequate salaries are provided so that the municipal system of doctors will retain its exceiient men and attract others, a most efficient service wirl be avai~able.'~ These submissions appear to have given the SRC the impression that the
SCPS was agreeable to a substantive municipal doctor system in rural
Saskatchewan within a ffs provincial health insurance plan:
...the fee-for-service method of payment is the one gencrally recommended by the CoUege of Physicians and Surgeons. Exceptions arc doctors in institutions, and doctors in arcas whcre the nwnber of patients is not suficient to support a doctor on this basis. They would also approve a modificd schrmc for nual districts of hiring doctors on a salary basis for general practice with extra fecs for surgay and special services." The subcommittee's endorsement of salaried municipal contract practice, without any qualifications, and the omission of the CMA/SCPS principle that salary remuneration be confined to areas where ffs was not feasible may have been due to the influence of R. K. Johnston, a salaried municipal doctor, and R. G. Ferguson, specialist(sa1ary) and father of Saskatchewanfs world renowned anti-tuberculosis
Both physicians, late appointments to the SCPS Central Health Insurance
Committee, served on the remuneration subcommittee. In a letter to subcommittee chairman Dr. J. A. Valens(private practitioner) outlining his views on physician remuneration in a provincial medical care scheme
Dr. Ferguson indicated that he was not opposed to salary remuneration for general practitioner services in the heavily populated areas of rural saskatchewan.76
As we shall see, R. K. Johnstonts fervent and vocal support for salaried municipal contract practice, coupled with the fact that
Johnston practised in one of the most prosperous farm districts in the province, would suggest that he, also, would not be in agreement with the CMA/SCPS principle that salary municipal doctor contract should be restricted to sparsely-settled and isolated areas of the province.
These views may explain the leadership's concerns with respect to professional unity, as well as complaints by private practitioners that there were too many salaried doctors on the SCPS8 Health Insurance
Committee(see Chapter 4, p. 85).
The SCPS briefs to both the Saskatchewan Legislature8s Select
Special Cornmittee on Social Security and Health Services and the
Saskatchewan Reconstruction Council were presented to the Health
Services Survey Commission chaired by Henry E. Sigerist, the third government-appointed inquiry into health services in 1943-1944. Municpal Doctors and SCPS Policy
Despite the SCPS official stance towards municipal contract practice, many municipal physicians appear to have been content with this form of medical practice. For example, in the March 1938 edition of the Canadian Doctor, R. K. Johnston, a salaried municipal doctor, stated:
At recurrent intervals articles appear in our journals referring to Municipal Conüact Practice, and so far, any that 1 have seen have spoken strongly against such practice. The remarkable part of this to me is thot ali that has been written against Municipal Contract Practice has ken written by doctors who have never held a municipal contract ... It bas been my custom to for some years, while attending medical conventions or district medical meetings. to contact other Doctors whom 1 lmew to be on Municipal Contract, to get theu views and without one exception they have all told me they considered it to be the ideal fonn of practice, patient and doctor both considered.... While îhe methoci of obtaining a municipal contract has at times been unfair and has proved a hardship to a doctor who was already giving good services to the district, and whik the contracts should be made to confonn more to a standard and passed on by a cornmittee representative of our own profession before bebg accepted by the doctor; still 1 do not feel that 1 am unethical in accepting a rininicipal contract...."
Dr. J. J. Collinsf 1941 suxvey also suggested significant support for the municipal doctor system:
The distnct or municipality being satisfied, our problem is to determine whether our municipal doctors are satisfied With some qualifications one might Say htthey are. Such remarks as these are quite clear on this point, - '1 like the system very much. Have been a Municipal Doctor for three years and am perfectly satisfied with my contract."- wThoroughlysatisfied afler twcnty-one years in Municipal practice." Others though voicing no great cornplaint desire some modification to ir" However, the replies to Dr. Collinsf questionnaire suggest that a majority of these physicians preferred a totally private ffs system:
What system of practice is the choice of the physician? ...ln the case of the Municipal Doctors, private practice seemed to be the type of practice of choice, but Municipal and State Medicine had many followers and Health Insurance a few.19
In terms of health insurance, as noted above, Dr. Collins reported that there was a question as to its feasibility in rural
Saskatchewan.
The particular concerna and interests of the municipal doctors with respect provincial medical services plan were manif est the
SCPS "special meetingn of March 18, 1942, when Dr. Lloyd Brown, President of the Regina D.M.S, moved that the college endorse *state- aided health insurance on a reasonable fee-for-service-rendered basis. "@O
However, as recorded in the Minutes:
Dr. J. J. Cotlins, Ituna, believed that there were many viewpoints on this question and maay things to be considered, as although ibis motion is to be the view of aii the doctors in Saskatchewan, yet there were 20% already in State Medicine. This proposal was based on three parties contributing, one king the Goverament, another the employer, which would be satisfactory for the urban people but not for the nual regions where there are mostiy fanners, and that this would have to be a provincial or a municipal matter for the raising of fun&. He did not think that the men present were prepared or had given much serious thought to be able to give an intelligent vote also that there were less than 10% of the professional men at this meeting."
Another salaried municipal physician, Dr. MacDonald of Ceylon, "agreed with Dr. Collins that it was impossible to work on an insurance plan as yet."'' Further discussion suggested support for salary remuneration among the municipal doctors:
Dr. Abrasom[municipal doctor] was questioned whether he would prefer a salary, and he replied in the affinnative." However, Dr. Brown's assertion that the resolution before the meeting could without pre judicing the position municipal doctors as it is left wide open as to local conditions and this was kept in mind when drawing up the resol~tion"~'appears to have assuaged the concerns of the salaried doctors; when Dr. Brown's resolution was put to a vote, it carried unanirn~usly.'~
The apparent support for contract practice among the municipal doctors was both affirmed and forcefully conveyed to the province's private practitioners by R. K. Johnston at the SCPS Annual General
Meeting September 16-17, 1943. Johnston's address may suggest that many municipal physicians disagreed with CMA/SCPS policy that in a national or provincial health insurance programme salaried contract practice should be restricted to the spareely populated and economically depressed areas of the province where fis remuneration was not feasible :
(b) Dr. R. K. Johnston of Eston miewed health insurance fkom the viewpoint of the municipal doctor: "-Ihave contacted many of the Municipal Doctors to get their views, and without one exception, they have told me they consider Municipal Practice to be the ideal form of practice, patient and Doctor considd... The Doctor feek fiee to camy out whatever treatment he may consider best, as only loss of tirne has to be coasidered. Eston is one of the mort prospaous fomiing districts in the province; the Municipal doctor schnmc was not introduced there as a direct relief measure...so 1 feel that Health Insurance can be worked equally satisfactorily for both health services.. .Many of you will not agree with what 1 have said, however, no subject is well dealt with untii it has been weii di~cussed."~~
Although Dr. Johnston indicated support for the salaried municipal doctor system, it is important to emphasize that he would not support a straight salaried system in the rural areas:
...At present municipal contracts allow Doctors to engage in outside practice. 1 would not concur in any plan of Health Inmrance which would take away the element of cornpetition or Limit the Doctor in the scope of his practice...y These latter sentiments appear to have been representative of the province's municipal physicians. In a summary of the cornments received from the 71 municipal doctors who responded to R. K. Johnstonls 1944
"questionnaire re Health Insurance," Johnston reported that the
"Municipal Doctors are not in favour of [salariedl State ~edicine.""
In addition, although "fairly well satisfied with this form of practice
(municipal contract plus private practice)," the respondents preferred ffs remuneration by 60 to 11.~' A survey conducted by the Central
Health Insurance cornmittee in early 1944 also revealed that the majority of municipal physicians preferred ffs remuneration:
The replies fiom the municipal men so far agree substantially that aay plan should be state- aided contriiutory health insurance with controt in the profession on medical matters. In the rnatter of remuneration there is some differcnce of opinion, although the tendcncy seems to be for a fee-for-ser~ice.~ The average municipal doctor was not simply a salaried physician.
Some municipal physiciansl earnings consisted almost entirely of their salary contracts. Municipal doctors surrounded by other municipal medical care plans and who did not perform major surgery, or did so on salary, relied on salaries. But for many doctors a substantial part of their income was on a private ffs basis. This private income consisted of bath general medical care and major surgery from within(vi1lages and toms) and outside the borders of the contracting municipality. The private income of some municipal doctors was equal to or exceeded their annual salaries. In this context the municipal doctor cannot be equated to a salaried civil servant as envisaged in a state salaried medical service.
The municipal doctors attached great importance to both their private income and private practice privileges, as evidenced by their efforts in the early 1940's to strengthen and enhance the scheme's private practice provisions via the introduction of a new "model" contract.
Several sunreys of municipal physician opinion undertaken in the late 1940's also indicated that the vast majority of the province's municipal doctors supported and desired the continuation of municipal contract practice that both included and permitted a significant amount of private practice. In terms of a province-wide medical services scheme, in the early 19408, many municipal doctors and rural-based private practitioners believed that contributory health insurance on a ffs basis, as advocated by the SCPS, was not financially feasible in many areas of rural Saskatchewan. In this context, many municipal doctors wanted to be able to continue to earn a living on a combined salary and ffs basis as municipal doctors or otherwise within a province-wide health insurance scheme. They did not, however, support the establishment of a salaried medical service.
The province's private practitioners were opposed to the salaried municipal doctor system from its inception. Beginning in the early
1930's organized medicine sought to have the municipal doctor scheme eliminated via the establishment of a province-wide ffs contributory
health care plan or a maternity care program. As early as 1934 the
SCPS presidency declared that municipal contract practice should be
reserved only for communities where, because of local conditions,
medical services could not be provided in any other way. This viewpoint was submitted as SCPS policy in the collegels submission to
the 1943-1944 Special Select Comrnittee on Social Security and Health
Services. This policy was re-iterated, albeit it would appeax with
more flexibility, in the SCPS submission to the Saskatchewan
Reconstruction Council in 1944. However, there was support among the province's salaried municipal doctors for the preservation and extension of the contract scheme beyond the poor and sparsely populated
areas where fis remuneration could not retain the services of a physician.
The province's salaried municipal doctors clearly were not the embryo of a state salaried rnedical service. Nonetheless, as we shall
see, the municipal doctor system was the basis of a conviction and hope among some residents in Saskatchewan that a salaried medical service could be established in this sparsely populated prairie province of
Western Canada. Endnotes:
' Saskatchewan Archives Board, Regina (hereafter SABR), Records of the Health Services Survey Commission (hereafter HSSC) file 34, "Medical Man Power Survey, M. D. #12, Statistical Report," (circa 1943), p. 14.
2 Joan Feather and Vincent L. Mathews, "Early Medical Care in Saskatchewan," Saskatchewan History, Vol. XXXVII, No. 2 (Spring, 1984), p. 50.
3 For an account of the developrnent of the municipal doctor system in Saskatchewan see C. RuhRorern, The "Municipal Doctor" System In Rural Saskatchewan (Chicago, Illinois: The University of Chicago Press, 1931); Feather and Mathews, supra, pp. 47-52; C. Stuart Houston, "Saskatchewan's municipal doctors: a foremer of the medicare system that developed 50 years later," op. cit., pp. 1642- 1644; Malcolm G. Taylor, Healrtt Insurance and Canadian Public Policy, op. cit., pp. 70-7 1.
R. K. Johnston, "We LLke Municipal Contract Practice!" Canadian Doctor, (May, 1938), p. 19; Saskatchewan Medical Quarterly (hereafter SMQ),Vol. 7, No. 1 (December, 1943), pp. 14- 16.
5 A rural municipality is a nual geographical unit of local govemment consisting of 6 to 12 townships, each township king an area of six miles square. It does not include incorporated towns and villages within its boundaries. During the 1940s, the majority of 302 mlrnunicipalities in the province were made up of nine townships or eighteen miles square, containing on average 2100 residents. Each niral municipality was administered by an elected council of one reeve and six councillors, with powers similar to those vested in the council of a village, town or city. R G. Ferguson, "Report of Cornmittee On Economics," Vol. 2, No. 4 (October, 1938), p. 16; Dr. R. O. Davison, "Municipal Medical Services in Saskatchewan," SMQ,Vol. 5, No. 3 (August, 194 1 ), p. 12.
Saskatchewan Archives Board, Saskatoon (hereafter SABS), Records of the Health Services Board (hereafter HSB), fde 2, "Health Services Board: Municipal Meâical Services," circa 1943, pp. 1- 4, 10-13; Health Services Board Submission to Select Cornmittee of the Legislative Assembly of Saskatchewan re. Social Welfare etc., Regina, March 28, 1943, pp. 4-5.
7 SABS, HSB, file 2, "Health Services Board, Municipal Medical Service, Rural Municipalities," (circa 1943- 1944), pp. 2-3.
SABS, HSB, file 2, "Health Services Board: Municipal Medical Services," (circa 1943), pp. 3, 10- 11.
SABR,HSSC, file 34, "Medical Man Power Swey, M. D. #12, Statistical Report," (circa 1943), Table 3.
' ' See, for example, Johton, supra, pp. 17- 19; SMQ,Vol. 7, No. 1 (Deccmber, 1943). pp. 14-16.
l3 In 1943, the Health Services Board reported thar 76 of the 106 rural municipalities or parts there of with municipal doctor plans had adopted the priaciples of the modcl contract. SABS, HSB, file 2, "Health Services Board, Municipal Medical Services, Rural Municipalities," p. 1.
" The Health Services Board was established in 1934 to ovnsee and rcgulate the municipal doctor system. The Board was comprised of equal representatives from the SMNSCPS, the Saskatchewan Association of Rural Municipalities, and the provincial govcrnmcnt. .. - -- ''SABR, Papers of Dr. John Michael Uhnch (hefcafler ührich Papen), füe 13.2, "Mode1 Municipal Physician Agreement: Memorandum for Dr. Davison," 15 May 1942. l6 SABS, HSB, file 2, "Municipal Medical Services of Saskatchewan, May 1941," p. 2.
17 At a SCPS meeting March 18, 1942, Dr. J. J. Collins presented a new model salary municipal doctor contract that he devised with the aid of a survey of municipal doctor opinions undertaken in 1941. This new contract streogthened and augmented the existing Health Services Board mode1 contract private practice provisions. First, physicians would contract with the municipality for 300 as opposed to 365 days of service. For services rendered on the 65 days not covered by the 30eday contract, Sundays, statutory holiciays and several days of vacation, the physician would be paid on a fee-for-service basis. Second, the mode1 contract explicitly stated the physician's right to engage in private practice outside the confines of the contrachg municipality. Third, municipal physicians would collect fees for al1 out of office calls, matmrity cases ($5.00), and travelling expenses. This model contract, which Dr. Collins claimed was a "representation of the average viewpoint of the municipal doctors," was approved by the SCPS May 20, 1942. Dr. J. J. Collins, "A Proposal for Modification of the Municipal Doctors Contract and Suggested New Model Contract," SMQ, Vol. 6, No. 1(April, 1942), pp. 15-26.
IB SABR, Uhrich Papers, file 13(2), "Model Municipal Physician Agreement: Memorandum for Dr. Davison," 15 May 1942.
I9 SMQ, Vol. 6, No. 2 (Aug~st,1942), m. 12-25.
SMQ, Vol. 6, No. 1 (Apd, 1943), pp. 17- 18.
" Dr. J. J. Collins, 'A Proposa1 For Modification of the Municipal Doctor Conûact: And Suggested New Model Contract," supra, pp. 15-16.
" SABS, HSB, füc 5, C. S. MacLean to Dr. Davison, 19 Febniary 1937.
25 SA@, Vol. 8, No. 4 (December, 1944), p. 18.
24 J. J. Collins, "State Medicine, Hcalth Insurance and Hiring Municipal Doctors," SMQ,Vol. 5, No. 4 (December, 194 1), p. 2 1.
2s SABR, HSSC, file 12, "Rural Municipality of Tisdale, HSPC re. Bnef on Medical Selvices, Sept 15, 1947," p. 4.
" SABR, HSSC, file 30. "Relevant Material in Pmfeedings of Select Special Committee on Social Security and Health Services," (unpaginated).
27 Rorem, supra, p. 74.
28 SWSCPS, Saskatchewan Medical Association, "Twenty-seventh AMual Meeting, August 20th 1934," p. 2.
29 Ibid., p. 3.
'O SMNSCPS, "Annual Meeting, September 22n4 23rd and 24th 1932 And Special Gen-1 Meeting, Saskatoon Saskatchewan, Febniary 28th 1933," pp. 25-26.
3 I Ibid., p. 31.
32 SWSCPS, College of Physiciam and Surgeons of Saskatchewan, Annual Repon, Septcmtm 1932, pp. 20-1. 33 Frank H. Coppock, "The Menace of Contract Practice," Canadian Docfor (March, 1938).
34 SWSCPS, "Minutes of the 28th Annual Meeting of the Saskatchewan Medical Association and the College of Physicians and Surgeons, September 24th 25th and 26th 1935," p. 8.
35 SMAISCPS, "Minutes of Meeting of the Joint Special Legislative Cornmittee," 15 January 1936.
36 Ibid.
37 SWSCPS, "Minutes of the Annual Meeting of the Saskatchewan Medical Association and the College of Physicians and Surgeons of Saskatchewan, September 22, 1936," pp. 5-6.
3 8 SMQ, Vol. 2, No. 4 (October, 1938), p. 22; SMQ, Vol. 3, No. 1 (Jan-, 1939), pp. 6-8. The Regina D.M.S passed and introduccd a similar resolution to the 1935 SCPS anaual meeting. SWSCPS, "Minutes of the 28th Annual Meeting of the Saskatchewan Medical Association and the Coliege of Physicians and Surgeons, September 24th, 25the and 26th 1935," pp. 3-4.
39 Robin Badgley and Samuel Wolfe, Doctors' Smmke:Medical Cure and Conflcr in Sashtchewan (Toronto: Macmillan of Canada, 1967), pp. 16- 17.
SMQ, Vol. 3, No. 4 (November, 1939), p. 22.
4 I Ibid., p. 16.
" Ibid., p. 17.
43 SMA/SCPS, file "Medical Services hcorporated Regina," Dr. G. K. Lindsay to Hon. R. J. M. Parker, Minister of Municipal Affairs, 28 Febcuary 1940; Davison, "Municipal Medicai Services In Saskatchewan," supra, pp. 12- 13.
U SMQ, Vol. 5, No. 1 (January, 1941), p. 6.
45 Dr. J. L. Brown, "Hiring Municipal Doctors," SMe, Vol. 5, No. 4 (December, 1941), pp. 25-26.
46 SABS, HSB, füe 2, "Municipal Medical And Hospitaiization Schemes, May 1, 1944."
47 J. J. Collins, "State Medicine, Health insurance and Hiring Municipal doctors, " supra, p. 13.
48 Ibid., p. 16.
49 Ibid., p. 17.
50 SABR, Uhrich Papers, file l8(4), A. W. Argue to the members of the College of Physicians and Surgeons of Saskatchewan, 2 March 1942.
5 1 SMQ, Vol. 6, No. 1 (April, 1942), pp. 46-47.
52 Naylor, Private Practice, Public Payment, op. cit., pp. 102- 107.
53 SMQ,Vol. 7, No. 2 (August, 1943), p. 12.
54 Ibid., pp. 29-30. - - s5 SMNSCPS, The Council of the College of Physicians and Surgeons of Saskatchewan, "Submissions To The Select Committee of the Legislative Assembly of Saskatchewan, March 1943," p. 4.
56 Ibid., p. 5.
57 SABR, HSSC, fde 30, "Relevant Material in Proceedings of Select Special Cornmittee on Social Security and Health Services," (unpaginated).
50 SMQ, Vol. 7, No. 7 (December, 19431, p. 19.
60 SWSCPS, file 2-9-4, "Bulletin #3 of the Central Health Insurance Committee," February 1944.
62 SMQ, Vol. 8, No. 2 (June, 1944), p. 10.
SMQ, Vol. 8, No. 1 (March, 1944), p. 9.
64 SMQ, Vol. 8, NO. 2 (June, 1944), p. 10.
65 Ibid.
66 SMQ, Vol. 7, No. 3 (December, 1943), pp. 27-3 1. There is no evidence in the Saskatchewan Medical Quarterly or the holdings of the SCPS/SMA Archives to suggest that this plan was ever officially endorsed by the SCPS; however, in September of 1944 Dr. Houston informed the Sigerist Commission that the SCPS annual meeting of September 1943 passed a "vote of approval" witb respect to this fee-for-service health insurance scheme. SABR, HSSC, file 12, Dr. C. S. Houston to Dr. Mindel Sheps, 6 September 1944.
" SMQ, VOL 8, NO. 2 (June, 1944), p. 8.
69 Ibid., p. 9.
70 Ibid., p. 8.
71 SMAISCPS, The Council of the College of Physicians and Surgeons of Saskatchewan, "Submissions To The Select Committee of the Legislativc Assembly of Saskatchewan, March 1943," p. 4.
72 SMQ, Vol. 8, No. 3 (December, 1944), pp. 9- 10.
73 Ibid., p. 14.
74 Saskatchewan Reconstruction Council, Report of the Saskatchewan Reconstruction Council, (Regina: King's Printer, 1944), p. 174.
75 C. Stuart Houston, R. G. Ferguson: Cwader against Tuberculosis, (Toronto: Hannah hstitute & Dundum Press, 1991).
76 SWSCPS, fde 2-9-6, Dr. R. G. Ferguson, 'Rmuneration of Physicians," circa 1944. n Johnston, supra, pp. 17- 19. 78 J. J. Collins, "State Medicine, Health Insurancc and Hiring Municipal Doctors,"supra, p. 18.
79 Ibid., p. 16.
80 SMQ,Vol. 6, No. 1 (April, 1942), p. 46.
8 1 Ibid., p. 52.
" Ibid., p. 54.
83 Ibid., p. 53.
84 ibid., p. 52.
85 Ibid., p. 53.
86 SMQ, Vol. 7, No. 1 (December, 1943), pp. 14- 16.
87 ibid., p. 16.
SMQ, Vol. 8, No. 4 (December, 1944), pp. 17- 18.
89 Ibid.
SMA/SCPS, file 2-9-4, "Bulletin #2 of the Central Health Insurance Cornmittee,"p. 1. THE POLITICS OF HEALTH CARE REFORM IN 1940's SASKATCHEWAN: HEALTH INSURANCE VERSUS STATE MEDICINE
Introduction
The "medical crisis" of the 1930's engendered broad public support for the establishment of a provincial medical services plan in
Saskatchewan that remained long after the hardships of the depression had ended.' The health care debate in the 1940rs, both prior to and after the CCF came to power, was not therefore about whether there should be a provincial or national medical services plan, but rather what form it ought to take. In this context, three government- appointed inquiries into health services and post-war reconstruction conducted extensive public opinion surveys with respect to provincial medical services in 1943-1944: the Select Special Cornmittee on Social
Security and Health Services; the Saskatchewan Reconstruction Council; and the Health Services Survey Commission.
This chapter will attempt to ascertain and assess the level of support for salary remuneration among the general public via an examination of the submissions to these inquiries. This chapter also documents the conflict between the State Hospital and Medical League and organized medicine over the direction of health care reform in
Saskatchewan. The findings of this chapter will facilitate a test of
Lipsetts hypothesis that the CCF government of Tommy Douglas did not follow the 1945 HSPC recommendations for a salaried medical service because of the lack of public support for euch a scheme. First, this chapter clarifies how the terms "state medicine," "health insurance" and wsocializedw medicine/health services were understood and utilized in Saskatchewan.
State Medicine, Health Insurance and Socialized Medicine
During the 1930's the tems "state medicine," "health insurance," and "socialized" medicine/health services were al1 used loosely and interchangeably in Saskatchewan to denote a province-wide medical services scheme.l However, by the early 1940'~~a consensus emerged among the medical profession, politicians, the press, and the plethora of lay organisations interested in health care reform that the establishment of a universal medical service scheme in the province entailed a choice between two distinct types of medical services schemes :
(llhealth insurance, with costs met from a fund created by persona1 contributions and state subsidy, the doctors paid by fee-for-service, capitation or by salary.
(2)state medicine, a non-contributory system financed entirely by taxation £rom general government revenues, in which members of the medical profession would be salaried civil servants.'
In this context, the term "socialized" medicine/health services was seldom used, with the important exception of the Saskatchewan CCF(see
Chapter 4.) Indeed, that term is virtually non-existent in the briefs, proceedings and reports of the Special Select Committee on Social
Security and Health Services and the Saskatchewan Reconstruction
Council. The few examples of its application in the 1940's suggest that socialized medicine/health services was used as a generic term for a medical services plan providing universal coverage, either in the form of contributory health insurance or state medicine. For exarnple, the introduction of the first edition (December 1943) of the SCPS'
"Bulletin" States that the object of this new communication is: To keep the medical profession in Saskatchewan in touch with the dcvelopwnt and tum in events dealing with sociaiized medicine, be it m the fom of Health insurance, or State Medicine .' Prior to the 1940'~~it would appear that only the leadership of organized medicine in Saskatchewan understood and defined 'state medicine" as entailing a salaried medical ser~ice,~predicated on their knowledge that the only national non-contributory medical care scheme in operation in the world. at that time, was that of the Soviet Union.
And in that country physicians were rernunerated on a salary basis. On the other hand, throughout the 1930's, and as late as the early 19403s, the term "state medicine" was used by the general public, the press, politicians and individual doctors (in the public sphere) to denote, and as a synonym for, medical care schemes with varying degrees of state involvement, including a contributory health insurance scheme.
For example, Dr. Uhrich, who would become the Minister of Health after the 1934 provincial election, in announcing the Saskatchewan Liberal
Party's commitment to "state medicine" in January of 1934 clearly envisaged a contributory health insurance scheme:
Any system of state medicine, of course mut be built upon a sound and practical foundation and the ideal plan, based upon the experience of oîher countries would appear to be one wherein the Dominion government the provincial govemment and the people as individuals wiU contniute to a state health insurance fund6 Moreover, Dr. Uhrich8s ifs contributory health insurance plan, which the Liberal government pledged to implement once the province's finances improved, was referred to by himself and the press as a scheme of "state medicine" at its unveiling in early 1935.' It was not until the late 1930's that Uhrich no longer referred to his contributory health insurance scheme as "state medicine." According to the Leader
Post(Regina), ührich told the Legislâture in March of 1939:
As far as state medicine was conccrned that was practised only in Russia, said Dr. Uhrich. He favourcd a contributory health insurance pian dong the lines of the British Columbia scheme and Saskatchewan's present contriiution to health insurance, on the basis of the B. C. Scheme to wbich the B. C. government contri%utes, would mean %17,000,000availabic for health insurance services.' As such, one must exercise caution in attributing support for a particular type of medical services scheme, let alone a salaried medical service, to organizations such as the Saskatchewan Association of Rural Municipalities (SARM) and the Saskatchewan Association of
Urban Municipalities (SUMA), even though throughout the 1930's they passed resolutions calling for the provincial government to implement state medicineS9 Indeed, it would appear that physician remuneration did not become an issue of public debate with respect to a province-wide medical services scheme until the 1940's.
Organized Medicine and the State Hospital and Medical League
Both contributory health insurance and salaried state medicine had their advocates and detractors who sought to influence government policy and public opinion as to which of the two schemes should be implemented on a province-wide basis.
From the outset of the medical crisis of the 1930'9, the leadership of organized medicine in Saskatchewan was opposed to state medicine. At the Saskatchewan Medical Association(SMA) annual meeting,
Scptember 10-11, 1931, the President Dr. A. McLurg warned:
Unless we can meet the problern we demand to have solved there is no doubt a solution will be found in the nature of state medicine. State Medicine should b the 1st resofi... It will prove destructive to individual initiative on the part of thc phyjician. It will cause a lessening of responsibility, a lowering of professional standards and reduce a great profession. We owe to our profession and to ourselvcs the duty of frnding a substitute that will be just as universal in its application and that will be just as effective but at more reasonable cos& and more in Linc with the traditions of ou.profession ....Io
Accordingly, in 1932 a Committee on Health Insurance was established.
And in 1933 the SMA endorsed, and began to actively seek public and state support for, a ffs contributory health insurance scheme." As Naylor notes, this initiative was undertaken in order to entrench
"existing practice patterns instead of 'state rnedi~ine.'"~'
In its first foray into directing lay opinion with respect to medical services policy the SMA achieved immediate success. At a meeting initiated by the SMA, June 6, 1933, representatives from the departments of Municipal Affairs and Public Health, the Saskatchewan
Hospital Association, SARM, and SUMA endorsed the principle of compulsory contributory health insurance.13 And in 1935 the Minister of
Health, Dr. Uhrich, unveiled a ffs contributory health insurance plan
(identical to the 1933 SM. scheme) that the provincial government promised to implement as soon as the province's finances improved.
However, the efforts of organized medicine to direct the popular movement for state-financed medical care under the umbrella of the
State Hospital and Medical League(SHML) met with failure.
The SHML had been established in the city of Prince Albert,
Saskatchewan on April 24, 1936. Convinced that the Liberal Government of Jimmy Gardner simply lacked the will to fulfil its 1934 election promise to introduce a provincial medical care pxogram, League founder
Alderman C. L. Dent of Prince Albert brought together a multitude of private citizens, farm, labour, and church organizations, c~perative groups and municipal governments that were, in the Leaguets words, interested in "socialized medicine or state control of health."14 The
Leaguets stated goal was to set up a "united frontw to devise, implement and promote the establishment of a provincial medical and hospital scheme. l5
The Chairman of the SMA Health Insurance Comrnittee, Dr. S. E.
Moore, recognizing the potential threat to the interests of organized medicine posed by the SHML, warned the SMA that: .. .shouid this young organization grow and become attached to any one state scheme of its own accord then the profession will be forced to do as directed, by the laity, rather than direct in a scheme with the medical view pointi6 Accordingly, as part of the SMA's on-going initiative to direct the popular movement for a provincial medical services plan towards a scheme congruent with the interests of organized medicine, Dr. Moore attended the meetings of the SHML in order to, in his words, "give guidance" to this organization.17
Meanwhile, in accordance with a resolution passed at the joint annual meeting of the SMA and SCPS September 22, 1936, the voluntary
SMA was merged with the SCPS.'' Thereby the SCPS became the only rnedical body in Canada with the dual function of both regulating the profession in the public interest and overseeing the interests of organized medicine.lg As Mombourquette notes, this initiative occurred one rnonth after a group of doctors issued a circular letter recommending amalgamation in oxder to confront the umany...serious problems ...standing at the door of the profession(e.g. Health
Insurance, State Medicine, etc.) ....II 20 Dr. Moore was elected President of the SHML at its first annual
Convention, October 15, 1936, and served on the Board of Directors along with the Presidents of the United Farmers of Canada, Saskatchewan
Section(UFCSS)and SARM.'~ However, the Leaguels membership eventually rejected a ffs contributory health insurance plan devised and promoted by Dr. ~oore.'~Dr. Moore was subsequently replaced as President by Dr.
Setka, a Prince Albert-based general practitioner who supported salary remuneration.23
At the SHML1s fifth annual convention, October 8-9, 1940, delegates endorsed the Leaguets "Eight Point Plan of State Medicine for
Saskatchewan," which envisaged a system of group practice clinics staffed by full-time salaried per~onnel.~'As an immediate step towards its plan for the establishment of a province-wide salaried medical service, the SHML lobbied the provincial government to extend the municipal doctor system "with al1 necessary provincial aid, financial and otherwise, to include al1 municipalities of the province as well as al1 the hamlets, villages, toms and cities and other organized
Throughout the early 1940's the League continued to expand its mernbership base and to acquire support for its health care proposals.
At the Leaguets annual convention, October 13-14, 1942, the executive declared that 296 organizations had affiliated with the League during
1942, an increase of 100 affiliations over the previous year.26 And by early 1943 each of the League1s proposed health care districts had an executive cornmittee organized to administer and help implement the
"Eight Point Plan. ""
It was in this context that Dr. Lloyd Brown, chairman of the SCPS'
"Publicity Cornmittee" and President of the Regina District Medical
Society, advised that, because of the "urgency of the situation," there be "no further delayM in launching the SCPS' so-called 'education campaign" to point out to the public "the advantages of Health
Insurance on the one hand, and the dangers of State Medicine on the other ."''
Between December 1942 and March 31, 1943, the residents of
Saskatchewan were inundated with newspaper and radio advertisements sucb as the following:
"HOW IS PATIENT NO. 29H406 today.. ." You don't want to be given a number when you're ill, do you? You don? want to be one of thousands in a card index. You don? want to be treated impersonally. State Medicine might mean al1 this. But Health Insurance protects you. Health Insurance permits you to consult the doctor of your choice ... HEALTH INSURANCE is recommended by YOUR DOCTOR.. ASK HIM ABOUT IT19
The S?3ML responded with its own radio campaign during this pexiod. It consisted of a series of addresses prepared and delivered by the Leaguets executive and senior officiais of its affiliated organizations such as the UFCSS, Saskatchewan Wheat Pool, and the Saskatchewan
Teachers ~ederation." SHML speakers maintained that the SCPS1 objections to state medicine were merely a facade for their opposition to salary remuneration:
What the CoUege of Physicians Surgeons really dreads is the idea of private practitioners being required to work on a salary basis, no matter how high, the rame as our municipal docton and those operating in our sanitaria and mental institutions."
These opposing public relations campaigns corresponded with the public hearings of the Saskatchewan Provincial Legislaturets 1943
Select Special Cornmittee on Social Çecurity and Health Services.
The Select Special Comminee on Social Secmand Health Services and the Saskatchewan Reconstruction Council: State Medicine or Health Insurance?
On March 2, 1943, Liberal Premier William J. Patterson appointed a bipartisan committee of 25 Liberal and CCF MLAs, chaired by B. D.
Hogarth, to enquire into "practical measures of further Social Security and Health Services for Saskatchewan by itself or in conjunction with the Government of canada....^'^ mer a period of five weeks, the committee heard representations from 38 organizations representing 'a typical cross-section of the people of the pr~vince.~"An additional four organizations, including the Saskatchewan Association of Urban
Municipalities (SUMA), submitted their views via written briefs.
During the hearings, the group of MLAs first sought to discern from each delegation before the committee which of the two contending medical care schemes they desired, a non-contributory scheme financed exclusively by the state from general taxation (state medicine), or a health insurance scheme funded by individual contributions. Once an organizationls preference had been established, the cornmittee's questions were primarily directed at ascertaining and exploring what form of contribution and/or taxation the various organizations envisaged. The cornmittee did not extract from the various delegations their preferences with respect to how doctors ought to be paid.
Indeed, a careful perusal of the proceedings reveals that with the exception of the SCPSt appearance before the Cornmittee, at which time the MLAs (particularly the CCF) questioned the doctors with respect to their opposition to the salary method, there was little discussion concerning physician remuneration during the hearings. Questions of finance were the Committeets main concern and focus."
According to a surnmary of the submissions, prepared by the Inter-
Sessional C~mmittee,'~the chief proponents of state medicine were the
SHML, UFCSS and the Womenls Section of this organization-" These organizations were opposed to a contributory scheme because, in their view, it did not provide protection for low-income groups, make adequate provision for preventive services, nor, as a perusal of the submissions and oral tcstimony of SHML and UFCSS will indicate, facilitate a re-distribution of physicians." To the suggestion that the government could assume the premiums and or persona1 taxes of those unable to contribute to the health insurance fund, the SHML stated it was opposed to a scheme that would oblige the less fortunate to accept charity. It should be noted in connection with the SHML and UFCSS objections that the supporters of contributory health insurance put great stress on the need for preventive services and a solution to the physician shortage in rural Saskatchewan.
The following lay organizations favoured contributory health insurance: SARM, Saskatchewan Homernakersl Clubs, the Bishops, Clergy and Laity of the Catholic Church of Saskatchewan, the Provincial
Executive of the Trades and Labour Congress of Canada, the Saskatoon Trades and Labour Council and the Moose Jaw Trades and Labour Council, the Medical Co-ops and the Catholic Hospital Conference."
It is worth emphasizing SARM1s preference for contributory health insurance over state medicine:
... pnor to 1940 Resolutioiis were adopted at our Annuai Conventions requesting the Government of the Province to inaugurate a system of State Medicine. Since ththe feeling has grown ha Governrnents .t*40 The aforementioned Municipal Medical and Hospital Services ActI permitted health services to be financed through a persona1 tax on the individual. Prior to this legislation, al1 [rural] municipal doctox plans were financed by a direct levy on property. As Dickinson notes in *The Struggle For State Health Insurance: Reconsidering the role of the Saskatchewan Farmer," the "farmers were interested in shifting the tax burden for health care from the property base to the individual/family unit."" SM'S position may have reflected a concern that if a non-contributory scheme was adopted in Saskatchewan, the farmer would bear an unequal taxation burden. The membership of the six Railway Transportation Brotherhoods was divided with respect to these two systems of medical tare." Based on this sumary, the Inter-Sessional Cornmittee concluded that "the preponderance of opinion voiced before the 1943 Committee favoured contributory Health Insurance as against State ~edicine."" With respect to physician remuneration, although the Special Committeets Final Report suggests support for the salary method among the advocates of both state medicine and health in~urance,~~a careful examination of the actual submissions to and proceedinga of the 1943 Comrnittee reveals that only the SflML and the SCPS indicated their preferences with respect to how physicians ought to be paid. The S?iML contended that Yhe fee for service custom does not encourage the preventive aspect of health service^,^'^ and insisted that al1 physicians be placed on salary. In addressing the differences in opinion with respect to physician remuneration, the Inter-Sessional Committee noted that, owing to the province's geography, whatever scheme was established "must take cognizance of, and continue where necessary some at least of the municipal schemes already in existence, in which the salary principle is well established."46 ~ccordingly,the Committee stated that "there would appear that there is room for both methods of remuneration.*" Although the Inter-Sessional Comrnittee made no specific recomrnendation with respect to how physicians should be paid, it recommended that that "the Commission appointed to administer the scheme take up with the College of Physicians and Surgeons the matter of a reduction in the Schedule of Fees."'' This statement suggests that the Cornmittee was resigned to ffs in whatever scheme was eventually established, with the exception of the outlying areas of low population dens ity . It is worth noting here, with respect to the Inter-Sessional Cornmittee recomrnendation concerning a reduction in the SCPS fee- schedule, that the 1942 annual SARM convention approved a resolution to the effect that the provincial goverment "enquire into the workings of the College of Physicians and Surgeons ...with special regard to the high fees set.m4g Dr. Uhrich, Minister of Public Health, was informed by the Secretary of SARM that: In support of the above Resolution it is ailcgtd that the fees of Medical Practitioncrs, particularly for major operations, are cxccssive and bcyond the paying ability of the average individual requiring these services.'O Indeed, at a SCPS meeting March 18, 1942, one physician warned the College that its latest proposed fee-schedule and payment dernands "would drive the people to State Medicine ...."51 As we shall see, this perception that SCPS fec-schedules were exorbitant was brought to the attention of the Saskatchewan Reconstruction Counciï(SRC), which held public hearings in 1943 -44. The SRC was established by the provincial government October 20, 1943, for the purpose of "formulating a CO-ordinated post-war reconstruction and rehabilitation planM for Saskat~hewan.~' To this end, the Council accepted submissions and heard representations from interested parties on al1 aspects of post-war development, such as agriculture, education, housing etc, including health and medical selvices. Of the many representationa, a total of 26 lay organizations outlined their views, however briefly, on a provincial medical services plan, or the delivery of health services to a certain class or group of individuals. Of these representations, only £ive indicated their preference with respect to physician remuneration in either a written submission, oral presentation, or during a cross-examination by the Councils' public bearing committee. The UFCSS and the Saskatchewan Teachers, Federation, for example, both of which supported the creation of a salaried medical service, confined their bxiefs primarily to agriculture and education issues and did not convey their support for salaried state medicine to the commission. Besides the SHML, the Regina Mutual Medical Benefit Association (a lay-controlled medical CO-operative) was the most insistent that ifs ahould be eliminated: Our members also consider that the professionai pupsproviding the services should be paid on a saîary or per capita basis and that the prcsent fee-for-semice bais should be discontin~ed.~~ The Emerald Revekah Lodge #22 lOOF of North Battleford, contending that the "doctors charges of today are too exorbitant," stated that they wanted physicians to be paid "fair not extreme" salaries and work an eight hour work day." The minutes of the North Battleford Teachers' Federationls appearance before Council suggests that this organization also envisaged a state salaried medical service.55 The Saskatoon Mutual Medical Benefit Association, maintaining that ffs was not conducive to preventive rnedical pra~tice,'~stated it was opposed to ffs unless there was a drastic reduction in the SCPS fee-schedule." In terms of financing, seven organizations indicated their preference for a contributory health insurance scheme: R. M. of Mantario, #262; both the Saskatoon and Regina Mutual Medical and Hospital Associations; the Saskatoon Local Council of Women; the Railway Transportation Brotherhoods; and the Saskatoon and Prince Albert Rehabilitation Council~.~~In addition, the Melfort R~co~s~Nc~~o~Committee stated that it was preparing for the implernentation of the Dominion Health Insurance Scheme (contributory); and the Regina Local Council of Women endorsed the provincial government s health insurance (contributory) proposals .59 Five organizations indicated their support for a non-contributory system of state medicine, as opposed to health insurance: Rural Municipality of Weyburn, UFCSS, SHML, Connaught Horne and School Association, and the Saskatchewan Teachersf Federation(North Battleford Local).60 The SRC would report its findings in August, 1944, after the CCF came to power. The Special Select Committee on Social Security and Health Services released its Final Report, on March 31, 1944.=' Noting that federal monies would be required for whatever acheme was implernented in the province, and that Ottawa had opted for a contributory format, the Committee stated that its decision between state medicine and contributory health insurance had been "more or less detennined for it;" and, as such, 'it became no part of their task to state a preference for State Medicine or Health ~nsurance.~~~'The conmittee recommended that the Legislative assembly "endorse the principle of health insurance for al1 the people of Sa~katchewan,"~~and set UP a commission along the lines outlined in the federal proposals to both prepare for and administer the anticipated Federal scheme. Should the federal legislation be delayed, as an interirn measure, the Cornmittee recommended an extension and further study of existing municipal medical and hospital schemes with the view of making them corripulsory in al1 municipalities and local improvement districts in the province." Accordingly, on March 31, 1944, the Liberal government introduced "A Bill Respecting Health Ins~rance,~*~~which pxovided for the appointment of a commission to administer the proposed federal plan. The latest draft of the proposed federal Health Insurance Act, devised with close consultation with the CMA, envisaged a contributory health insurance scheme financed by 1) 125 registration fee; 2) a personal income tax levy; and 3) a contribution from the Federal Go~ernrnent.~~The contentious area of physician remuneration, whether on ffs, capitation or salary, was left to the provinces to decide. Curiously, the Final Report of the Special Select Committee on Social Security and Health Services did not discuas, let alone make any recommendations concerning physician remuneration. It is also worth noting, in the context of the Saskatchewan CCF supposed cornmitment to a salaried medical service, that the CCF rnembers on the Committee did not submit a minority report recommending salaried physicians. The SHML was a vocal critic of the proposed federal health insurance legislation in its various drafts during 1943-1944. Concerning the first draft legislation, the SHML declared that: the main feature of the Drafi Biil is to create a collection agency for the Medical Profession, as no limit for medical services is esîablished and no salary basis proposed? The Saskatchewan Teachersl Federation(STF), an affiliate and strong supporter of the SHML, attacked the 1944 draft legislation on similar grounds. At a meeting of the STF Provincial Council in early 1944, the Secretary of this organization, J. R. Cumming, stated the following: It's easy to see why the medical profession supports the heath inninince scheme. They wrote the bill. The whole thing would be a grand collection agency for the medical profession. We won't get state medicine under health innwice. 'There is no provision for adequate hospitakation or for adequate medical senrices, for diagnostic and rcmedial treatments, but it does provide for the same fee-for-service that we now have." Mr. Cumrningts cornrnents were made in connection with the adoption of a resolution that called for council to request that the SHML lobby the provincial government to establish a system of state medicine, and that similar pressure be placed on the federal government to take a similar action.69 The federal proposals were also criticized by the Saskatchewan CCF, albeit apparently not with respect to physician remuneration. Mr. O. W. Valleau, the CCF1s chief representative on the Special Select Cornmittee of the Legislature on Health Services, objected to the proposed administration of the federal plan,70 but "he could not vote against the bill because of the urgency of health in~urance."'~ Subsequently, the Liberal's Health Insurance Act passed unanimously and received royal assent April 1, 1944, in the final days of the last session of the Legislature. Thereafter, the 1944 provincial election campaign began in earnest. Within eight weeks of the CCF8s decisive victory, the Social Reconstruction Council(SRC) submitted its Final Report. The SRC acknowledged the "strong representations [that] were made with respect to state medicine," but concluded, "after due consideration," that a recornmendation for the immediate establishment of state medicine 'as opposed to the [proposed Federal] Plan for health insurance would not be ~arranted.~'' Several factors were cited "in reaching this conclusionM: 1) the province "could not hope to finance a complete system of state medicinen; 2) it appeared that federal assistance was contingent upon the acceptance of the Dominion health insurance plan; 3) the "lack of administrative experience in this field ...necessary for success"; and 4) the "very strong professional opposition to state medicine. w73 Accordingly, the SRC endorsed "state-aided health insurancem(the SCPSI terminology for contributory health insurance) ." In terms of physician remuneration, the SRC recommended that al1 doctors be paid on a ffs basis except in areas where this would result in a shortage of doctors.'' In these areas, the [health insurance] Commission should guarantee a minimum payment to the doctor sufficient to assure his services."76 These recommendations were essentially the physician remuneration policy of the SCPS. Health Services Survey Commission Public opinion with respect to health care delivery in Saskatchewan was canvassed yet again in the relatively short period of 1943-1944 following the 1944 provincial election. This time various organizations and private citizens subrnitted briefs and made oral presentations to the CCF-appointed Health Services Survey Commission(HSSC), which held public hearings in September of 1944. Of the three inquiries into health services in Saskatchewan in 1943-1944, the HSSC received the most submissions. A large and diverse number of local government, farm, and citizen organizations of various orientations, as well as trade unions, appeared before the Comrnittee. Twenty-four individual rural and urban municipalities and several umbrella organizationst7' such as SARM, seven trade unions; the province's four medical services CO-operatives. two agriculture organizations, and four, what the HSSC referred to as, "citizens' organizations" submitted briefs to the Commission." A further three lay organizations of various orientations, the Saskatchewan Hospital Association, Saskatoon Constituency Association(CCF) and the Saskatchewan Old Age Pensioners' Association outlined their views on a provincial medical services scheme. Of these organizations, the following indicated their preference for a contributory health insurance scherne: (1)SARM; (2)M. S. Anderson, Reeve of Mckillop; (3)R. M. Pittville; the (4)Regina,(5)Saskatoon and (6)Melfort Mutual Medical Benefit Associations(Medica1 Services Co- operatives); (7)"local unions #43, #IO0 and #186 of the Canadian Brother hood of Railway Employees and other Transport Workers of Regina, Saskatchewan; (8) Canadian Daughters League ; and ( 9) the Provincial Council of Women;and (10) the Saskatchewan Hospital Asso~iation.'~In addition, the Moose Jaw & District Labour Council appears to have favoured a system of state medicine, but felt that contributory health insurance must be established as a first step towards this objective. The following organizations indicated their preference for a non- contributory scheme of state medicine, and or voiced their support for the SHML1s "Eight Point Plan" for state medicine: (1)SHML; (2) R. M. of Big Quill, no. 308; (3) R. M. of Connaught; (4) Prince Albert Mutual Medical Benefit Association(Medica1 services Co-operative);(S) UFCSS; (6) Saskatchewan Federation of Agriculture, "representing the organized Producers and Consumers' Co-operatives" and the UFCSS;(7) Regina Trades and Labour Council; (8) Saskatoon Trades and Labour Council ; 9) Saskatoon Constituency Association (CCF); and (10) the Saskatchewan Old Age Pensioners' Associati~n.~' The position of the Joint Legislative Committee of the 6th Railway Transportation Brotherhood is noteworthy for its neutrality with respect to debate between state medicine and health insurance. The trade union's contention that the general public was indifferent may be suggestive: Thcse are kaown as State Medicine, or Health Insurance Plans and while there is a wide divergence of opinion between the proponents of the two systems we find the average laymen is indifferent and unconcemed as to the various principles advocated, but is only concemed with the portion of a system of Medical Care that will meet with its particular needs. We have thmfore adopted a neutral position with the advocates of these system~.'~ In terms of physician remuneration, al1 ten of the aforementioned advocates of state medicine indicated their support for a salaried medical service their briefs by voicing their support for the SHML proposals and/or stating directly that the doctors should be placed on saïary. For example, the Regina Trades and Labour Council stated that: It would seem to us that the best approach the govemrnent cam make to medical service, is through the medium of salaried doctors operating in evenly distributed health centres throughout the Province. As you are undoubtedly aware this is similar to a plan which has been proposed for the Commonwealth of Australia, and has been suggested by the Saskatchewan State Hospital and Medical ~ea~uel' The Saskatchewan Federation of Agriculture noted its brief that supported the Canadian Federation of Agriculture~s state medicine proposals, "which would eliminate the fee for service system."" But in the meantime it "endorsed the representation and program submitted to this commission by the State Hospital and Medical League .f'BS Several proponents contributory health insurance also advocated the discontinuation of ffs remuneration. The Regina, Saskatoon and Melfort Mutual Medical Benefit Associations, like the Sm,al1 maintained that ffs remuneration was not conducive to preventitive medicine. For example, the Melfort CO-operative stated that : Fee-For-Service is a detriment to the practice of prcvcntivc or curative medicine: it is an incentive to unnecessary surgery, while a per-capitation is an incentive to prtvcntive medicine and makes possible a vastly improved health smice." In an addendum to the SCPS1 brief to HSSC by Dr. J. F. C. Anderson, took exception with these daims: The Coilege deplores such statements as "the Medical Profession is not concemed with preventive care," and that "Fee For Service Cannot Support Prevmtive Health mic ces."" The Regina and Melfort CO-operatives recommended that doctors be placed on salary or capitation. The Saskatoon Mutual Medical Benefit Association, despite its position that ffs could not support preventive health services, did not make a similar recommendation." However, on October 4, 1944, the Saskatoon medical CO-operative, with an enrolrnent of 2000 persons, launched a campaign to obtain a membership of 5000 that it believed would be required to support a group practice clinic with a staff of 6-9 salaried doctor~.~~The CO-operative's failure to obtain discounts from the SCPS and the CO-operation of many Saskatoon doctors for its rnodest reimbursement plan appears to have been the impetus for this initiati~e.~' A memorandum supported by 'local unions #43, #100 and #186 of the Canadian Brotherhood of Railway Employees and other Transport Workers of Regina, Saskatchewan," recommended contributory health insurance with doctors "rernunerated on a fee-for-service basis(the only lay organization to do so in al1 three public in qui rie^)."^' The remaining supporters of contributory health insurance, including SAM, did not state theix position on physician remuneration. Although SAM does not appear to have had an officia1 policy with respect to physician remuneration, an account in the Saskatchewan Medical Quarterly of a SCPS/SARM meeting in early 1944 may suggest that this organization was congenial to ifs payment: A committee of the Council met the Executive of the Association of Rural Municipalities in Regina carly this ycar. Much good came of this meeting. A definite basis of understanding was rcached. We found thm highiy favourablc to a contnibutory health schemc. They were appreciative of the senrices king rcndered the people of rural areas in tùese trying timcs and wmwilhg to stand for fair remfor services rendmdn The Commissioner of the HSSC, Dr. Henry Sigerist, submitted his report to the government of T. C. Douglas on October 4, 1944. Unlike the two previous government-appointed inquiries into health services in Saskatchewan, Sigerist did not debate the merits of, or make a recommendation with respect to, state medicine and contributory health insurance. For the cities, he recommended "a system of compulsory health insurance, the details of which would have to be worked In rural Saskatchewan, the municipal doctor system should be extended. He made no recommendation as to how these schemes should be financed, i.e. general revenues or direct taxation/premiums- In terms of physician remuneration, Sigerist endorsed the salary method, but he did not cal1 for the medical profession to be placed on salary(see Chapter 4, pp. 91-92)." In the early 1940's a consensus emerged in Saskatchewan that the establishment of a provincial medical care plan entailed a choice between two distinct medical schemes, distinguished by their financial rnake-up and to a lesser extent how physicians would be paid: 1) contributory health insurance funded by personal contributions (prerniums or a direct persona1 tax) and a state subsidy; and 2) state medicine, a non-contributory scheme financed exclusively by the state £rom the consolidated revenue fund raised through general taxation in which the medical profession would be salaried civil servants. Curiously, a ffs non-contributory-scheme, i.e. state medicine on a ffs basis, such as contemporary Canadian medicare, does not appear to have been envisaged. It was assumed that if medical services were funded from general government revenues doctors would be paid by salary. Salaried state medicine was supported by a broadly-based, well- organized and vocal popular movement for a provincial medical services plan under the umbrella of the State Hospital and Medical League. So strong was this movement that the SCPS launched a comprehensive and sophisticated public relations campaign to counter this perceived threat to its interests. With the exception of the Select Special Cornittee on Social Security and Hcalth Services, which observed that a 'preponderance of opinion favoured contributory health insurance as against state medicine," the submissions to the three public inquiries into health services in the province in 1943-1944, demonstrated the solid, province-wide support for the establishment of a state salaried medical service in Saskatchewan. A total of ten organizations indicated their support for salaried state medicine to the HSSC, equalling the number of groups that submitted briefs in favour of contributory health insurance. Moreover, these endorsements of salaried state medicine included the two agriculture organizations that appeared before the commission, the United Farmers of Canada, Saskatchewan Section and the Saskatchewan Federation of Agriculture, "representing the organized Producers and the Consumersm Co-ope rat ive^."^^ These endorsements cal1 into question the validity of Lipsetls imputation that the "famers supported 'state' medicine but to them the term meant state payment of medical care... [and not a state salaried medical service]."96 Although there appears to have been broad support for both contending health care systems, SARM1s preference for contributory health insurance over state medicine may suggest that there was also considerable support for the establishment of a contributory health insurance plan as opposed to a scheme of state medicine. An examination of SARM briefs to the three inquiries into health services in 1943-1944 suggests that this organization did not have an officia1 physician remuneration policy. However, a SARM commu11ication with the SCPS in early 1944 may suggest, as College officia16 inferred, that it was congenial to ffs payment. In this context, it is worth noting that the SHML claimed that it was strongly Usupported in the municipal field by the Urban and the Rural Municipal ~ssociations.~~~~In view of SARMts health care positions, perhaps public support for the Leaguets policies was not as strong as the SHML claimed. Moreover, SARMfs definite endorsation of contributory health insurance as opposed to state medicine challenges the Leaguets contention that it represented and spoke for the "great majority of the citizens of Saskat~hewan."~' Nevertheless, the SHML clearly commanded a great deal of support for its "Eight Point Plan,*f as evidenced by the significant number of organizations of varying orientations and stature - rural municipalities, farm, labour and citizens' groups, e-g. the Saskatchewan Pensionerfs Association, chat indicated their support for this programme to the HSSC. Endnotes: ' The drastic fall in the pnce of wheat tbat foilowed the coliapse of the New York stock exchange in October 1929 devastated Saskatchewan's agriculture-based economy. Depressed grain prices coupled with severe drought in some regions of the province rendered many individuals and fdesin both rural and urban Saskatchewan unable to afford Me's necessities, including basic medical care. Undcr these conditions the existing physician shortage in rural Saskatchewan became even more acute, as an ever- growing number of country doctors, unable to secure a living, abandoned their practices to re-establish in the cities and more prospemus localities within and outside the province. In order to prevent a major exodus of medical personnel, in November of 1931 tbe provincial government authorized the newly established Saskatchewan Relief Commission to issue grants of $40 to $75 per month to nuai-based doctors in relief areas as an incentive to continue practising, But this initiative did not case the cost of medical care to the gencral public. Consequently, throughout the Great Depression of the 1930's, a plethora of lay organizaîions and individual citizens lobbied the provincial government to establish some kind of provincial medical care plan. Feather, "From Concept to Reality: Fomtion of the Swift Current Health Region," Prairie Forum,Vol, 16, No. 1 (Spring, 1991), p. 64. Taylor, Malcolm G. Taylor, Health Insurance and Canadian Public Policy, op. cit., pp. 73-75. For an account of the personal hardships borne by the patient and country doctor in 1930's Saskatchewan see Jacalyn Duflin's description of the contents of Dr. Hugh MacLean's "Medical Services During the Depression" file in "The Guru and the Godfather: Henry Sigerist, Hugh MacLean and the Politics of Health Care Refonn in the 1940s Canada,"Canadian BulZenn of Medical History, Vol. 9 (1992), pp. 199-202. * See for example, "Party Leaders Give Strong Suppoa To State Medicine League Program: Outline Views On Its Development," Western Producer, 22 Octokr 1936. ' Saskatchewan Archives Board, Regina (hereafier SABR), Records of the Legislative Assembly Office Unpublished Sessional Papers, LXVIX, 1, Select Special Committee on Social Security Bnefs and Exhiits, 1943 - 1944 (hereafter USPSSC), file 40, "Suggested Agenda for Cornmittee to Enquire into Legislation Relations Relating to Social Welfare," p. 1; Select Special Committee on Social Security and health Sentices, "First Report of the Select Special Committee re Social Welfare, etc," Saskatchewan Legisfative Journal, April 12, 1943, Appendix., pp. IV-V; Select Special Committee on Social Security and Health Services, Final Report, (Regina, 1944), p. 10; Saskatchewan Reconstruction Council, Report of the Saskatchewan Reconstnrction Council, (Regina: King's Pinter, 1944), pp. 168- 174. 'SasAorchewan Medical QuurterZy (hereafier SMQ ), Vol. 7, No. 3 (December, 1943), p. 5. 5 Archives of the Saskatchewan Medical Association and the Saskatchewan Coilege of Physicians and Surgeons (hereafter SMA/SCPS) College of Physicians and Surgeons of Saskatchewan, Annual Report (September I932), p. 22; Saskatchewan Medical Association and the College of Physicians and Surgeons, Annual Report (1936), p. 12. "State Medicine, Insumace, Assurcd by Liberals; Says Uhnch," Leader Pmt, 22 Jmulry 1934. ' J. M. Uhrich, "PUBLIC HEALTH AND STATE MEDICINE: Speech Dclivered by the Honourable J. M. ührich in the Budget Debate in the Legislative Asscmbly of Saskatchewan, January 28, 1935," Journal of the Sarkatchewan Legislamre, Session 1934 - 1935, p. 19; "State Medicine Pian For Future Told by Uhrich: Scheme Seen as Solution for Sask. Medical Problems by Health Ministcr," Leader Post, 29 January 1935; "Editorial: State Medicine for Saskatchewan Favourable," Leader Post, 9 March 1945. "Public Health Improves, Says Uhrich," Leader Post, 8 March 1939. -- - For example, at its Annual Convention in January 1936, SARM overwhclmiagly codorsed a molution calling for the Federal and provincial govcrnments to UIiplement "statc medicine" at the eprliest possible date. Taylor, supra, p. 74. 'O SMA/SCPS, Saskatchewan Medical Association, Annual Report (193 l), p. 7. Il SMA/SCPS, College of Physicians and Surgeons of Saskatchewan, Annual Report (September, 1932) p. 2 1. 12 Naylor, Private Practice, Public Payment, op. cit., p. 66; 13 Taylor, supra, p. 74. 14 SABS, Pamphlet Collection, State Hospital and Medical League, Second Addition," 30 September 1936. IS Ibid. 16 Saskatchewan Medical Association and the College of Physicians of Surgeons, Annual Report (1936), p. 12. 17 SMNSCPS, "Minutes of Annual Meeting: Saskatchewan Medical Association and the College of Physicians of Surgeons: September 221.1423rd, 24th 1936," p. 14. 18 Ibid., p. 11. 19 Taylor, supra, p. 24 1. 'O Duane Mombourquette, "A Govemment and Healtb Care: The Cosperative Commonwealth Federation in Saskatchewan, 1944-64." M. A. Thesis, University of Regina, 1990, p. 36; Saskatchewan Archives Board, Saskatoon (hereafter SABS), Records of the Health Services Board (hereafter HSB), file 14, circular letter to ail doctors fiom the "Cornmittee for the Group" of physicians who studied the medical situation in Saskatchewan, 28 August 1936. " "State Medicine Urged for Saskatchewan," Leader Post, 16 October 1936; "Sîate Medicine League in First Convention Decides to Urge Plans upon Govt," Western Producer, 22 October 1936. " "Social Service Council to Aid State Medicine Scheme," Regina Star, 28 May 1937. U SABS, Pamphlet Collection, "Saskatchewan State Hospital And Meâical Lcague, Fourth Annual Convention, Saskatoon, Sask., October 20, 1939," p. 6. SABS, Pamphlet Collection, "Rcpon of the Fifth Annual Convention of the State Hospital and Medical League, Saskatoon, October 8th and 9th, 1940," p. 9. 2s University of Regina Library, Special Coliections (hereafter URLSC), "Brief for Submission to the Govemment of the Province of Saskatchewan, October 15, 1943, State Hospital and Meâical League," cited in The State Hospital and Medical League, The Case For State Medicine, (1944), p. 8. SABS, Pamphlet CoUection, "Report of the Sevcnth Annual Convention of the "State Hospital And Medical League, Odd fellow's Hall, Saskatoon, Oct. 13th & 14th, 1942," p. 1. 27 Feathcr, supra, p. 65. 28 SMQ,Vol. 6, No. 2 (August, 1942), p. 44; Vol. 5, No. 4 (Dccernber, 1941 ), pp. 30-32. 29 SSMAISCPS, füe "Publicity Cornmittee," Sample of advertisements placed in the Leader Post (Regina), Saskatoon Star Phoenix, Moose Jow Times, and Rince Albert Dai& Star. 30 URLSC, J.H. Wesson (President, Saskatchewan Wheat Pool and Vice-Resident, Canadian Federation of Agriculture) A Review of "Healih on the March": A Pamphlet issued by the Canadian Federation of Agriculture, radio address delivered over CKBI and CJRM, March 28, 1943; Geo. R. Bickerton (President, United Famiers of Canada) "The Wealth of Hedth," radio addtcss delivered over CJRM and CFQC, May 2, 1943; Mrs. Mabel Bradely (President, United Farm Women, Regina) "State Medicine and its Possïbilities: A Cal1 to Action," radio address delivered over CKBI and CJRM, February 23, 1943; Jas. H. Cumming (Secretary, Saskatchewan Teachers' Federation, Saskatoon), "Unwarranted Expense and Tragic Toll of Unorganised Medical Care," radio address delivered over CJRM and CFQC,March 7, 1943. Cited in nie State Hospital and Medical League, The Case For State Medicine, (1944). " URLSC, P. G. Makamff, K. C., Saskatoon, The Municipal Doctor, Health insuance, Co-operative Insurance And Other Altematives," radio address delivered over CJRM and CFQC,Febniary 2 1, 1943. Cited in The State Hospital and Medical League, The Case For State Medicine, (1944), p. 24. 32 Saskatchewan Legislative Journal, Marc h 2, 1943. 33 Select Special Committee on Social Security and Health SeMces, "First Report of The Select Special Committee re Social Welfare, etc," Saskatchewan Legislative Journal, Apnl 12, 1943, Appendix, pp. IV-V. " SABR, Records of the Health Services Survey Commission (HSSC), file 30, "Relevant Material in Proceeduigs of Select Special Committee on Social Security and Health Services,"(unpaginated). 35 The Select Special Committee was unable to complete its task before the end of the 1943 session of the Legislature. An inter-sessional Committee was appointed to continue îhe inquiry after prorogation and report to the reconstituted Select Special Cornmittee early in the next session of the Legislature to the end that a "Final Report" could be tabulated. Select Special Committee on Social Security and Health SeMces, "First Report of The Select Special Committee re Social Welfare, etc," Saskatchewan Legislative Journal, April 12, 1943, Appmdix, p. Vm. 36 SABR, USPSSC, file 39, "Inter-Sessional Committee on Social Security and Health Services: Report to Select Special Committee on Social Security And Health Services Session 1944," p. 4. 37 Ibid., pp. 5-6; SABR, HSSC, file 30, "Relevant Material in Proceedings of Select Special Committee on Social Security and Health Services, "(unpaginated). 38 SABR, USPSSC, file 39, "Inter-Sessional Committee on Social Security and Health Services: Report to Select Special Committee on Social Security And Health Services Session 1944," p. 5. 39 SABR, USPSSC, file 6, "Recomrnendations To The Select Committee Of The Legislative Assembly of the Saskatchewan Legislahire re Social Welfare Etc. by The Saskatchewan Association of Rural Municipalities," p. 2. Harley Dickinson, "The Struggle for State Health Insurance: Reconsidering the Role of Saskatchewan Fanners," Siudies in Political Economy, 4 1 (Summer, 1993), p. 147. 42 SABR, USPSSC, file 39, "inter-Sessional Committce on Social Security and Health Semices: Report to Select Special Committee on Social Security And Health Savices Session 1944," p. 5. " Ibid. 6s Taylor, supra, p. 77. 66 Select Specinl Committee on Social Security and Health Services, Final Reprî, (Regina, 1944), p. 10. 67 URLSC, "Brief for Submission to the Govemment of the Province of Saskatchewan, October 15, 1943, State Hospital and Medical League," cited in The State Hospital and Medical League, ReCare For State Medicine, (1944), p. 7. 68 "Health Insurance Scheme Attached by S.T.F. Semtary at Conference," Leader Post, 2 January 1944. 70 Mr. Valleau objected to the proposed commission's lack of responsibiiity to the Legislative Assembly with respect to the dtafting of regdations and expenditure. 7' "Health Act criticized," Leader Post, 1 April 1944. 12 Saskatchewan Reconstmction Council, Report of the Saskatchewan Reconstruction Council, (Regina: King's Printer, 1944), p. 172. '' Ibid. " Ibid., p. 176. 7s Ibid., pp. 173- 174, 188-189. l6 Ibid., p. 188. 77 The vast majority of the submissions by individual nual and urban rnunicipalities were strictly requests for assistance in procuring the services of a physician or the constnrction of local hospitals. 78 Henry E. Sigerist, Saskatchewan Health Semces Survey Commission: Report of the Comrnjssioner, (Regina: King's Printer, 1944), pp. 13- 14. 7 9 SABR, HSSC, file 2, "Recommendations To The Health Services Commission of the Saskatchewan Government by The Saskatchewan Association of Rural Municipalities," p. 2; "A Brief presented to the Health Services Commission at its hearing in Regina, Sask, September 26, by W. J. Burak, Secr-Treas. R M. Pittville, Hazfet, Saslc," p. 20; file 12, "Recommendations as submitted to the Provincial Health Services Survey Commission by M. S. Anderson, Reeve of the Rural Municipaiity of McKillop No. 220"; fde 8, "Submission by the Regina Mutual and Medical Benefit Association," p. 5; "Supplemental Brief In Conjunction With The Melfart Medical Co-op Brief On Health Services[prcscnted by Saskatoon Mutual and Medical Benefit Association]," p. 6; "MelfortAnd District Mutual Medical Benefit Association Limited (Brief prcsented Septernbcr 16, 1944.)," p. 1 1; fde 5, "Mcmorandum Respecthg Health Insurance, Public Health Services, etc. Submitted to the Health Service Survey Commission of the Province of Saskatchewan, September 26,1944, by the Local Unions of the Canadian Brother hood of Railway Employees and other Transport Workcrs, Regina, Saskatchewan," p. 1; file 7, "Brief Prcpared, Submitted by The Canadian Daughters' League, Asscmbly No. 23, Regina, Septcmber 1944," p. 1; file 7, "Submission presented to the Health Services Swey Commission on behalf of Provincial Council of Womcn, held in Saskatoon, September 18, 1944," p. 3; file 4, "Saskatchewan Hospital Association, Brief to Survey Commission on Public Health," p. 1. 'O SABR, HSSC, file 5, "Brief For Submission To The Commission Appointed To Make A SweyOF The Health Semices In Saskatchewan: Submitted By The Moose Jaw & District Labour Council At Moose Jaw Sask. September 27, 1944," p. 2. SABR, HSSC, file 2, D. Demarias (Scaeiary Treanuer Rural Municipality of Big Quill No. 308) to Mindel C. Sheps & accompanying "Resolution"; file 5, "Brief on behalfof the Regina Trades and Labour Congress," file 8, "Prince Albert Mutual Medical Benefit Association, Ltd: A Bnef to be presented to the Saskatchewan Health Se~cesSurvey Commission at Saskatoon, Tuesday, September 19, 1944," p. 2; file 6, United Farmers of Canada (Sask Section) "Mernorandwa on "Social Health Services" to Saskatchewan Enpuiry Commission, September 1% 1944.," p. 2; file 6, "Submbsion To the Saskatchewan Health Survey Committee," Saskatoon, September 19th144 (Saskatchewui Federation of Agriculture)," p. 1; füc 5, ItBrief submitted by P. W. Haffner for the Regina Trades and Labour Congress," pp. 2-3; file 5., Saskatoon Trades and Labour Council, September 19th 1944; file 10, Fred Gordon (Semtary CCF Saskatoon Conmitucncy) to Secretary Sigerist Commission, September 16,1944; füe 27, "Report of Sittings Held At Saskatoon - September 20, 1944 ( Saskatchewan Old Age Pensioners Association's declaration that they endorsed the State Hospital and Medical League Eight Point Plan For State Medicine)," p. 1. 82 SABR, HSSC, file 5, "Submission by Joint Legislative Conmittee of the 6th Railway Transportation Brotherhood." 83 SABR, HSSC, file 5, brief submitted by P. W. Hafiber for the Regina Trades and Labour Congress," p. 2. " SABR, HSSC, file 6, "Submission To the Saskatchewan Health Survey Committee," Saskatoon, September 19thl44(Saskatchewan Federation of Agriculture)," p. 1. 85 Ibid. 86 SABR, HSSC, file 8, "Melfort and District Mutual and Medical Benefit Association Limited," p. 10. " SABR, HSSC, file 3, "Addendum of Dr. JFC. Anderson., Saskatoon, Sept, 1944," p. 2. SABR, HSSC, füe 8, "Supplemental Brief In Conjunction With The Melfbrt Medical CO-OPBrief On Health Services [presented by Saskatoon Mutual and Medical Benefit Association]," p. 4- "Local Medical Co-op To Launch Drive For Memh," Sashtoon Star Phoenix, 4 October 1944. 91 SABR, HSSC, file 5, "Memorandum Respecthg Health Insurance, Public Hedth Services, etc. Submitted to the Health Service Survey Commission of the Province of Saskatchewan, Septembers 26, 1944, by the Local Unions of the Canadian Brother Hood of Raiiway Employees and other Transport Workers, Regina, Saskatchewan," pp. 1-2. 92 SMQ, Vol., 8, No. 4 (December, 1944), p. 8. 93 Sigerist, supra, p. 6. 94 Ibid., p. 10. 95 SABR, HSSC, füe 6, "Submission To the Saskatchewan Herlth Swey Committee," Saskatoon, Scptember 19th/44," p. 1. " Lipset, AgraMn Sociafism, op. cit., p. 297. - - -- 97 SABR, HSSC, He8, "Bricfpresented at Saskatoon to Doctor Sigcrist and the personnel of the HSSC fiom the State Hospital & Medical League of the Province of Saskatchewan," p. 1. 98 SABS, Pamphlet Collection, "Submissionby The Statc Hospital and Medical League, Regina, Saskatchewan, To The Hoa Brooke Claxton, Minister of Health, Ottawa, Canada, May 30, 1946," p. 1. The Co-operative Commonwealth Federation, Henry Sigenst and Physician Remuneration Policy in Saskatchewan: 1 93 7 - December 1945 Introduction The CCF1s rise to power in Saskatchewan coincided with demands for radical reform of the ffs system. This chapter examines the partyls position on salary remuneration prior to and during the 1944 provincial election; and as the government of Saskatchewan during its first eight months in office. The CCF Health Care Policy and the 1944 Provincial Election: Salary or Fee-For-Service? The "Hancibook to the Saskatchewan CCF Platform and Policy," issued in 1937, is the earliest document cited by scholars in support of their assertion that the party originally cnvisaged a provincial medical services plan in which al1 physicians would work on a salaried basis.' This document seems to have been written by Dr. Hugh MacLean, a Regina-based surgeon and Vice President of the Saskatchewan CCF until his departure to California in 1938 for health reasons. It appears to be a verbatim excerpt from a text Dr. MacLean delivered as a radio address on March 17, 1937, in the capacity of Vice President of the Saskatchewan CCF, and as a speech to the annual convention of the Woments Parm Organization on June 2, 1937, in saskatoon.' Lipset presents an extensive quotation from the 1937 Handbook in Agrarian Socialism to substantiate his claim that the CCF was opposed to a health insurance scheme, which he defines as a ffs medical services plan in which the "doctors would continue to practice exactly as they did under private medicine."' The CCF, Lipset maintains, envisaged a salaried medical service in which "the emphasis would be changed from curative to preventive measures."' Doctors would be "paid to keep people well rather than to tseat their ail ment^.*^ Stan Rands provides a similar interpretation of the 1937 Handbook in Policy and MacLeanls text is primarily a call for greater and more equitable access to modern medical care without charge to the patient. It is in this context that MacLean spoke of the need for "preventive medicine."' MacLean did not imply that the medical profession was not engaged in preventative medicine because they were remunerated on a ffs basis as opposed to salary, but rather because the majority of citizens at the time could not afford medical treatment and only went to a physician when an illness was at a critical stage: The matter of payment or non-payment for rnedical services is probably not the most pemicious evil. With ali the advances of medical services we canwt make them available to a very large number. In our present system of practice, prevmtive medicine is largely neglected because the members of the [medical] profession are almost wholly engaged in the curative end of practice, so that preventable deaths are not king prevented and comctable conditions are wt being comcted because the people are not in a fmcial condition to have their condition disco~ered.~(This excerpt fiom MacLean's text is quoted in Agrarian Sociolism with the crucial exception of the clause ''because the people are not in a financial condition to have their condition discovered") MacLeanls ideas concerning the organization of a future health care system constitute a very small portion of the text, are not fully elaborated, vague, and quite ambiguous. Statements can be easily found and interpreted to support pre-conceived ideas about CCF physician remuneration policy. For example, MacLean's references to and praise for the provincial tuberculosis and cancer treatment programmes, and the municipal doctor system (al1 of these health care plans employed salaried physicians) in the context of his call for state control of health care do not necessarily mean that he was advocating, let alone envisaging, a state salaried medical service. There is, however, one passage in MacLeanls text concerning curative medical practice in a future health care system that could be interpreted as supportive of a salaried general practitioner service: Hmalso the Mative side of practice could be undertaken with the hospital at the centre. The doctor could then do the work that for which he is best suited and especially traincd and then he could devote his energies not to the competition of securing a living, but to the saivmg after better results. The nurse couid also be employed..(the later two sentences are quoted by Lipset in Agrarian ~ociulin)~ However, MacLean may have simply been referring to the fact that in a state-financed medical services plan, physicians would be relieved of the often difficult task of collecting from their patients, price- cutting. and the anxiety of securing an adequate income because payment for their services would be guaranteed by the government. The removal of this burden would also allow the physician to "devote his energies not to the competition of securing a living, but to the striving after better res~lts."~~Even if the latter interpretation is accepted, one rnay suggest that the former staternent does not in itself provide sufficient evidence for a daim that the Saskatchewan CCF envisaged the establishment of state salaried medical service. In any case, no where in Lipsetfs excerpt from the 1937 CCF Health Plank, MacLean's radio address and speech to the Woments Farm Organization is there a declaration that a CCP government would place physicians on salary. One can safely state that there is no cornmitment to salary remuneration in the 1937 health care plank in its entirety, for surly Lipset would have quoted such a pledge in Agrarian Socialism to support his assertions. Subsequent policy papers and statements issued by the Saskatchewan CCF leading up to and during the 1944 provincial election campaign, unlike those of the National and Ontario CCF in 1943," did not suggest, let alone declare, that a CCF government would place doctors on salary; nor do the resolutions pertaining to health services policy passed at the Party's annual provincial convent ions .l7 In 1943-1944, as part of the 1944 provincial election campaign, the CCF health care policy was set forth in the following documents: 1) "CCF Program for Saskat~hewan,~first issued in November 1943 and reprinted April 1944; 2) a pamphlet "Let There Be No Blackout of Health;" and 3) a newspaper advertisement "The CCF Plans ~ealth."'~ In these documents, as well as resolutions passed at the partyts annual conventions, the party promised to set up a complete system of "socialized medicine with a special emphasis on preventative medicine so that every resident of Saskatchewan will receive adequate medical, surgical, dental, nursing and hospital service without charge."14 As noted in Cbapter 3, by the early 1940's there was a consensus in Saskatchewan that there were two distinct genre of medical services schemes: 1) contributory health insurance; and 2) state medicine financed from general taxation with doctors on salary. In this context, the term socialized medicine was seldom used in Saskatchewan, with the exception of the Saskatchewan CCF. As noted in Chapter 3, the few instances of this term's application suggest that socialized medicine was understood as a generic term for a medical services plan providing universal coverage, either in the form of contributory health insurance or state medicine. None of the aforementioned CCF policy papers, nor summaries of the CCP health policy in Saskatchewan new~papers,'~suggest that the CCF or the Saskatchewan public understood the partyls pledge to implement socialized medicine as a cornmitment to salaried physicians . In fact, none of the above mentioned CCF policy statements indicate how the CCF believed health care should be financed (via taxation or persona1 contributions) and doctors paid. Health policy resolutions passed at the partyls annual conventions are similarly vague, with the exception of the 1943 CCF convention -resolution on social services." This resolution states that "provincial and federal government contributions to cover al1 costs should be made out of the Consolidated Revenue fundsffr16suggesting that the CCP stood for state medicine. In terms of physician remuneration, however, the resolution merely states that: al1 payments for professional services renderd should be made on the basis of a mutuaiiy acceptable contract for services. l7 The resolution supports McLeod and McLeodfs contention in Tommy Douglas: The Road to Jerusalem that the Douglas-Fines Executive decided in 1943 that a provincial medical services plan should be financed with ngeneral government revenues," but "the question of whether doctors should work on salary or receive a fee for each service provided was lef t open. "la Nevertheless, the behaviour of some party members may have led some observers at the time to believe that the party supported a state salaried medical service. First, as noted in Chapter 3, the supporters of a scheme financed entirely frorn general government revenues(i.e. state medicine) in Saskatchewan, as opposed to individual contributions (premiums or a personal tax), were, without exception, in favour of a salaried scheme. Second, the party itself attacked and criticized contributory health insurance using the language of the supporters of salaried state medicine. The CCF, like the SHML and UFC, for example, claimed that health insurance "only covers those who can afford to pay the insurance premiums" ; 'it does not provide adequate facilities for preventive medicine," etc.lg However, criticism of contributory health insurance did not necessarily imply support for salary remuneration as Rands and Lipset sugge~t.~OIt was understood in Saskatchewan that in a health insurance scheme doctors could be paid on salary, capitation or ffs. As noted in Chapter 3, the medical CO-operatives, one of the most vociferous opponents of ffs remuneration in the province, prefened a scheme of contributory health insurance, with doctors on salary or capitation, to state medicine. As such, the supporters of salaried state medicine, let alone the CCF, did not attack health insurance because it did not entai1 the placing of doctors on salary. Third, prominent members of the party were active in the SHML. P. G. Makaroff, Vice President of the CCF in 1940-1941 and "a leading party member outside the ~egislature,"~~was on the SHML executive and an outspoken advocate of salary remuneration." And the Saskatoon CCF constituency inf9rmed the 1944 Sigerist Commission that it endorsed the SHML 'Eight Point Plan for State ~edicine.~,~~However, the "CCF Program for Saskatchewan" stated categorically, albeit tactfully, so as not to alienate the Sm, that it did not support the Leaguets "Eight Point While the C.C.F. is not committed to the support of the League's plan, the C.C.F.commends the work the League has done and approves the careful study of its planz4 Despite the ambiguity surrounding the activities of some party members and officiais it is apparent that the CCF did not have a clear policy on physician remuneration, let alone a cornmitment to a state- salaried medical service, prior to and during the 1944 election campaign. Health care was, however, at the centre of the 1944 Saskatchewan provincial election çampaign. Next to agriculture policy, health and education received the most attention by party candidates and speakers. 25 The CCF led an al1 out assault on the Liberal government's health care record, and its platform reflected this campaign issue. The party levelled a multitude of accusations to the effect that the Liberal government had neglected the health care needs of Saskatchewan people: mortality rate for infants was "twice as high as it needs to bew; preventive medicine was "almost completely neglectedu; and most importantly, "thousands of people are going without medical treatment because they cannot afford it."" In addition, the CCF argued that the federal government's health insurance proposals were "no+ enough to meet the health care needs of the people.*" Echoing the SHML and other proponents of state medicine, the CCF maintained that health insurance only covered those able to afford the insurance premiums and did not make provisions for preventive services. The CCP stated further that there were not enough doctors, or adequate facilities in rural Saskatchewan for treatment and diagnosis . None of the parties, however, indicated how they believed doctors should be paid in a provincial medical services scheme. Physician remuneration was not an issue in the 1944 provincial election. Except for a proposa1 to set up a non-political body similar to the Board of Directors of the Saskatchewan Anti-tuberculosis League to administer health services, the CCF programme was short on details. The YCF Program for Saskatchewan" declared that "in working out its health planstt a CCF government would '~eek,"~and hope to obtain, the support of doctors and nurses. But it might "have to rely mainly on the younger doctors and nurses with a more progressive view point than that of some of the older mentbers of the professions.w30This pledge to seek the CO-operation of the medical profession was re- iterated in "Let There Be No Blackout Of Healthm and the "CCF Plans Foy Health," minus the disparaging remark with respect to the health care views of older physicians. The CCF declared that a complete medical and hospital service could not be implemented imnediately, but in stages, as the province's resources allowed. As an immediate step towards this objective, the party promised to irnmediately assist municipalities in financing municipal doctors and hospitals, expand the municipal doctor system to cover the two/thirds of rural Saskatchewan without such schemes; build health centres, and establish travelling clinics.'' The CCF plan to expand the municipal doctor system was not considered radical in Saskatchewan. This policy had been endorsed by the Saskatchewan Legislaturets Select Special Committee on Social Security and Health Services(1943-44) and the Saskatchewan Reconstruction Council. The CCF plan of action, in contrast to the Liberalts questionable commitment to health insurance contingent as it was on federal finances, contributed to the partyts landslide victory at the polls in June of 1944. Following the 1944 election victory, Dr. Hugh MacLean, who would act as the Premier Douglasf external adviser on health care policy during his tenure as Miniater of Public Health from 1944 to 1949, gave an address on health services to the Saskatchewan CCF convention on July 13, 1944. Jacalyn Duffin and Leslie A. Falk in "Sigerist in Saskatchewan: The Quest for Balance in Social and Technical Medicine" state that MacLeanms address "appears to have been the blueprintn for Sigeristts report.12 In the area of financing, MacLean declared: The matter of fmancing healtb services should corne largely if not altogether fiom the consolidated revenues to which ali people contnbute according to their ability to pay?' In terms of physician remuneration, MacLean's address suggested a persona1 preference for salary remuneration. For example, after praising the medical care plan of the Kaiser Ship Building Corporation in the United States, based on group practice clinics staffed by salaried doctoxs, MacLean stated that the Kaiser plan: demonstrates to the medical profession and to others that there can be fodmedical mm of high caii'bre working for a saiary adequate to the skiii of the doctor rendering it Also ht those who carry out this plan are not fearfd of regimentation nor the stult-g of personal initiative...?* However, he did not cal1 for the establishment of a state salaried medical service. MacLean stated that either "salary or a fee-for- service" could be employed in a provincial medical services plan, such as "in the Workmenls Compensation Actn or 'on a system to be agreed upon by consultation by the medical profession and the Government ."" Moreover, whatever the choice : No scheme can or should be put into operation without asking for the CO-operationof the medical profession." Preparation for Salarieci State Medicine? When the CCF took office in June of 1944, party leader T. C. Douglas became Premier of the province of Saskatchewan. At Dr. Hugh MacLeanls suggestion, Douglas also assumed the portfolio of Health Minister, signalling the importance his administration would place on health reform." Preparations began at once to enable the new government to implement its health platform. The Premier's first act as Minister of Public Health was to appoint Dr. Mindel Cherniak Sheps of Winnipeg, a general practitioner, as his assistant. Mr. Thomas H. McLeod, an economist and then persona1 assistant to the Premier, was assigned to work with Dr. M. Sheps." The choice of Dr. Sheps was very much a political appointment to insure that the government had personnel that were sympathetic to its health care objectives. She chaired the Manitoba CCF reseaxch committee on health and was a member of the national CCF research committee on health.39 Mindel and her husband Dr. Cecil G. Sheps, who was serving as Director of Venereal Disease Control for the Canadian Anny in Alberta before he joined ber in 1945," were staunch socialists with family members among the upper echelons of the Manitoba CCF.~' CCF activists with deep roots in the CCF rnovement's urban prairie stronghold, Winnipeg's North End, the Sheps oversaw the Douglas government's health reform initiatives in the formative and turbulent 1944-46 period. Mindel Sheps' first task was to assist an ad hoc Commission to conduct a comprehensive health survey of the province. According to Malcolm G. Taylor, the government decided that the survey should first *provide a series of explicit objectives and prioritiestW and second, "dramatize the government's thrust in health services."'' Premier Douglas told Dr. Hugh MacLean that the Veal object" of this survey was to 1) determine 'the actual needsw of the province, and 2) "set out the more immediate steps that are essential to meet these need~."~~Dr. M. Sheps was appointed secretary to the Commission. Dr. Henry E. Sigerist, physician and internationally renowned professor of medical history at Johns Hopkins University, Baltimore, Maryland, was contacted and agreed to lead the survey. At the time of his appointment, Dr. Sigerist was a highly respected, yet controversial commentator on the need for universal prepaid medical care services; he was an expert and advocate of the Soviet health care system." Prior to his sojourn in Saskatchewan, Sigerist had made several high-profile visits to Canada in the early 1940's at the invitation of progressive individuals and organizations, such as the Canadian Association of Medical Students and Interns, and the Health League of On these occasions he gave laudatory addresses on the Soviet health care system and stressed the need for universal access to modern medical care, or, in his words, to rectify the imbalance between the "technical" and *socialN aspects of medicine.'= During his third visit, in February of 1944, he addressed the Social Security Committee of the House of Cornons, where he first met T. C. Douglas, Sigerist had already accepted an offer from the national CCF to make a cross-Canada lecture tour when the Saskatchewan CCF was swept to power on June 15, 1944. The speaking tour was cancelled in order to allow Sigerist to accept Premier Douglas1 request to lead the Saskatchewan survey." Dr. Sigeristls health care ideas at the time of his appointment were set out in an article published in the July 1944 edition of the Canadian Journal of Public Health. It is based on his address to the Social Security Comrnittee of the House of Cornons on February 10, 1944. Regarding the remuneration of doctors he wrote: There are three ways of remunerathg doctors under a heaith insurance scheme Cl) fee-for- service; 2) capitation; 3) salary]... The third, and in my opinion by far the best method, is for the fun& to appoint physicians on salaries graded according to experience, responsibility, and hd.The advantages of such a system are obvious... 1 am well aware that the idea of bebg saiaried employees does not appeal to the majority of doctors, because it is not the traditional fom of remuneration. They also fear that a salaried system might reduce their initiative. The experience in other contries, however, has shown that if salaries are adequate ... the doctors are-very soon reconciied with such a system and appreciate the security and independence it gives them." In this context, the appointment of Dr. Sigerist to conduct a health survey in the province would have been, with out a àoubt, viewed with suspicion by the SCPS. In other circles, particularly the SHML and its affiliated organizations, securing Dr. Sigerist rnay have been interpreted as a signal that radical health care policies could be expected in post-war Saskatchewan. Indeed, during its presentation to the 1943 Select Special Comrnittee on Social Security and Health Services, the SHML recommended that the provincial governrnent hire Sigerist to undertake a survey of health conditions in Saskatchewan sirnilar to those he had conducted in the Soviet Uni~n.'~ As Jacalyn Duffin notes in "The Guru and the Godfather: Henry Sigerist, Hugh MacLean and the Politics of Health Care Reform in the 1940s CanadaN : Tommy Douglas seems to have chosen Sig& to head up the survey because he was a distinguished outsider, wiîh impeccable credentials, whose endorsement of the CCF plans would be difficult to criticize. They had met in Ottawa the preceding Febniary and, given Sigerist's previous high-profüe visits to Canada, the prior contract with the CCF, and hk inteniatioaal reputation as an authority and a scholar, the choice seems to have been a foregone conclusion. But T. H. McLeod, Douglas' former economic advisor, said that the premier would not make any big decision without consultation with bis experts and for health, the expert was "Doc ~ac~ean."" In this context, it is worth mentioning that Dr. Hugh MacLean, back in California, questioned Sigeristls appointment and suggested two other professionals with expertise in medical economics: We discussed Dr. H. E. Sigerist....Ail agree that he is a very schoiarly gentleman who knows a great deal of the history of Sociology and Medicine. No one could better give a lecture on the need of extending the medical services to all the people such as has been done in Russia but we are rather afkaid the he may not have the background of economics necessary to put into operation a system such as Saskatchewan should have...A is my opinion that the ground is ready for sowing the seed. As 1 mentioued in my address, the people and the profession have already been educated on the nedl MacLean s assessrnent the potential contribution of Dr. Sigerist to the survey suggests that the medical historiants appointment was motivated prirnarily by the govexnment's objective to attain province- wide publicity for its health reform agenda. To the Premier's disappointment, Dr. MacLean declined an invitation to serve on the Commission, insisting that there would be too many out-of-province physicians on the survey c~rnrnittee.~~Instead, MacLean proposed that Dr. Lloyd Brown of Regina represent the medical profession, as Brown was head of the SCPS medical economics ~ommittee.'~ Dr. Brown agreed to serve on the HSSC with the Collegevs consent and an understanding that the Report submi t ted by Dr. Sigerist would not necessarily be of Dr. Brown's own opinion.'' Mr. Clarence Gibson, Superintendent of the General Hospital in Regina, Mrs. Ann Heifel, School Nurse, and Dr. J. L. Connel, dentist, made up the rest of the survey tearn. Dr. MacLean also recommended that the survey committee include Mr. E. R. Powell of the State Hospital and Medical League: It would be politic to have someo~Say, Wre E. R Powell, who has doue a geat ded of research work in aiis problem and has written that linle book recmtly entitled the Medical Quest. 1 un not sure whaher or wt he would be hard to handlc but if you could have him tied into it you might swing that quite large body belonging to the State Hospital and Medical ~eague." Dr. MacLean8s advice, however, was disregarded. No lay persons were appointed to the Commission. Dr. M. Sheps began her duties as secretary to the Commission, August 14, 1944. Dr. Sigerist was to arrive in Regina September 6, 1944, at which time the Commission would commence its tour of the province. While this flurry of activity occurred within the government, the SCPS was at work on a number of fronts preparing for the developments that lay ahead. The College set up a negotiating committee to deal with the new government on "matters of medical interest, especially health in~urance."'~The College negotiating committee was comprised of the following physicians: Drs. U. J. Gareau(private practitioner), J. L. Brown (paediatrician), J. F. C. Anderson (specialist) R. K. Johnston(municipa1 doctor) 0. M. Irwin(private practitioner), R- G. Ferguson(sa1aried specialist), the President and Registrar, R. W. Kirby and A. W. Argue(private practitioners) ." The SCPSI initial fears about a CCF government appear to have subsided (at least with some SCPS officiais), as the CCF unveiled its health care agenda. In a letter to Dr. T. C. Routley of the CMA dated August 1, 1944, a SCPS official wrote: Since that time we have had, as you know, an election in this province and the new party installed.. ..fÏom what 1 can gather, it lwks as though they are just going to enlarge the present arrangements that are in force for municipal doctors, which seems to be satisfactory to most people, the doctors inciuded in this province. They also announce that they are going to look after the hospitalization and medical care of the Old Age Pensioners ....However, they are setting up a Health Commission, 1 understand, htis going to have doctors on it and also laymcn, who have been working with Hospitals, to look aftcr hospitalization and the medical care of al1 these people. As far as 1 can sec it is not going to be so vcry revolutiomry, but they do ablater to bpve somcthing dinmnt cstablished? Still, several actions undertaken by the SCPS, as well as comments by the leadership and rank and file private practitioners indicate a certain anxiety about the future. First, in the SCPSI on- going conflict with the State ~ospitaland Medical League, the College sought the assistance of the CMA. At a meeting of the SCPS Medical Council July, 20, 1944, College Registrar, A. W. Argue, and J. F. C. Anderson, chairman of the Collegels publicity cornittee, were requested to obtain the aid of the CMA in preparing a reply to a recent SHML submission to the Saskatchewan Reconstruction Council(SRC) that the College felt contained inaccurate data." Second, the Chairman of the Central Health Insurance Committee, Dr. Gareau, noted at the SCPS annual general meeting September 18-20, 1944, that "there had been some criticism of the [SCPS] Negotiating Cornmittee personnel in that it was thought too many were salaried men."60 Third, an "appeal for unity in the medical profession was made.m61 Moreover, at the SCPS annual meeting of September 1944 Dr Gareau declared that: The big task that needs yet to be completed is that of orgaukhg the profession, one step in this direction was the appointment of Keymen to obtain the signatures of aii doctors ... when [the] men return hmoverseas the profession should work as one unit in trying to un@ the practice of rnedi~ine.~' It was iu this atmosphere that Premier Douglas met with the SCPS Negotiating Committee on August 23, 1944, to discuss the establishment of a medical care plan for old age pensioners and other social assistance beneficiaries. The Old Age Pensioners Scheme According to Malcolm G. Taylor's account of the negotiations of August 23, 1944, based on correspondence with Dr. C. J. Houston, "differences in their ideological approaches" emerged? But "despite their differences in philosophy ...the basic understandings on the operation and the costs of the social assistance rnedical care program were agreed upon.*" Doctorsl payrnents would be made on a prorated ffs basis, to be drawn from a pooled sum representing $9.50 per capita. A formal offer consisting of the above terms was sent to the College September 13, 1944,65 and was accepted October 1, 1944. On January 1, 1945, the approximately 25, 000 old age pensioners, blind pensioners, farnily allowance recipients and children who were wards of the state were eligible for free hospital and medical services. McLeod and McLeod suggest that ifs payment was at the insistence of the SCPS.~~Even so, C. J. Houston's account of the negotiations does not suggest that Douglas tried to obtain a medical services plan with doctors on capitation or salary. According to Houston's correspondence with Malcolm G. Taylor, at the meetings of August 23, 1944, Douglas informed the College that he wished to provide medical services to old age pensioners and other wards of the state and "asked for suggestions, about rnethods costs etc."67 Houston writes further: My recollection is that there was no pre-selected position defended by either side. Both sides agreed that this was a special group justifjmg special treatment - and both sides were intrigued by the fact that this could be used as a special group to provide figures on which costs of friture programmes couid be more reaiisticaiiy caiculated. Douglas wanted a programme for the pensioner's now! We offered him a practical way of doing it. He agreed in principie!' These negotiations and their outcome may have been an early indication that the CCP's chief aim was the provision of state-funded medical services to the people of Saskatchewan as rapidly as possible. In this context, the method of payment for rnedical services appears to have been negotiable and, one may even suggest, immaterial to the CCF. The negotiations also indicate that Douglas was comrnitted to a policy of CO-operation with the medical profession. Despite Douglas' acceptance of ffs in the government's first medical care agreement with the College, the future of ffs medicine in Saskatchewan was far from certain. As Taylor notes, the "agreement did not deal with the main issue, a universal health insurance program.w69 It was presumed by many, in both medical and lay circles, that the Douglas government's policy concerning a province-wide medical care plan would be detennined to a considerable extent by the outcome of the health survey now underway. The Health SeMces Survey Commission: September 6 - Oct 5, 1944 Dr. Sigerist arrived in Regina on September 6, 1944, just two days before an Order-in-Council officially established the Health Services Survey Commission(HSSC). The Order-in-Council, approved and ordered by the Lieutenant Governor, September 8, 1944, stated that the Commission was for the purpose of: having an exhaustive study and inquiry made into and concerning existing health services and schemes of al1 types in Saskatchewan as weU as hospitals, nursiag homes, and aU equipment or buildings available for the extension of health senrices, and Mer, to make a study of existing and potential facilities for training aU types of health personnel, and for these pwposes to consult with aU organizations, and to include in bis consideratious any questions which he may hold to be relevant and to recommend to the Government of the Province of Saskatchewan a program which will provide for the extension of the above services and facilities to ail parts of the Province in a more integrated and efficient rnanner and to make any recommendations he considers advisable for further study which will help in nich a plan.'0 This extract from the HSSC mandate suggests that the government had already decided the structure and content of the health system it hoped to establish in Saskatchewan, i.e. an expansion of the province's municipal doctor scheme, hospital system, and public health infrastructure, etc. Indeed, as we shall see, Dr. Sigerist would state precisely this when questioned by SCPS officials. Pollowing several days of meetings at the Legislature, public hearings were held in Regina on September 11-12, 1944. On September 13, 1944, the HSSC began its tour of the province. Initially, the medical historian's public statements confinned both the highest expectations of salaried medicine supporters, and the worst suspicions of the College. In an interview, published in the Regina Leader Post September 7, 1944, Dr. Sigerist praised and explained the health care system of the Soviet Union, consisting of health centres staffed by physicians remunerated on a salary basis according to experience, responsibility, and hazard. Sigerist called this type of delivery system 'organized medicine. " During the interview, he also countered private practitioner's criticisms of salary remuneration with the same logic voiced by the SHML: The charge that orghtion will destroy the doctor's initiative does not hold water, any more than it would for teachers." Hence, with Dr. Sigerist, the SHML and its affiliated supporters of salaried medicine received publicity for theix health care ideas, most notably, their "clinic plan," modelled as it was on the Soviet health care system. Dr. Sigerist's appointment and initial pronouncements may have fuelled expectations that health care policies along the lines advocated by the SHML would be implemented by the Douglas government when the war ended. However, a week after Sigerist's comments, on the first day of the HSSC tour of the province, Premier Douglas said: '*Our goal is state medicine, organized medicine, or sociaiized medicine, caii it what you We. But it does not Unply that every medical man will be employed as a civil servant," he said. It would not be practical to establish a system in Saskatchewan under which ali doctors were servants of the state. The geographical make up of the province made necessary the inauguration of a systern of whereby the= wouid be govcmment health doctors, municipality paid doctors and private practitioners. The health se~ceplan as erivisaged by his govment, said the premier, would be a combination of provincial and municipal services operating in conjunction with pnvate practice. The program would be directed by the Saskatchewan government, with municipal and private doctors cc~opcratingto provide medical services to aii residenîs in the province regdess of theu ability to pays7' Douglas1 statements, however, may not have precluded the possibility of Dr. Sigerist recommending a state salaried medical scheme in his report to the provincial government. In his posthumously published autobiographical writings, Sigerist claims that he had sole responsibility for the Commissionls report: 1 have the Statu of Beveridge, that is, 1 alone will be responsible for the report and the other members act as technical advism. in this way we are sure to avoid a minority report." This fact was clear to both advocates and opponents of salaried state medicine, as the proceedings of the SCPS Annual General Meeting on September 18-20, 1944, indicate. Dr. Kirby's Presidential address to the annual gathering of the province's physicians suggests that College officials were optimistic but anxious about the future. The Premier's pledges of CO-operation seem to have reassured the SCPS leadership of the governrnentls intentions, but the doctors were clearly concerned about Sigeristts forthcoming report. Kirby stated: We have the assurance of Premier Douglas that the present govemment proposes to work with the medical profession in setting up any Health Insurance scheme. This pronouncement, while gratimg to us, clearly canies with it an important respomibility as CO-partner in the formative stages as well as in its irnplementation ...We are ali to have the opportunity of hearing Dr. Sigerist, the Chaimian of the Cornmittee...Dr. Sigerist has already outlined his view in a recent publication of the[Canadian] Journal of Public Health, wbich no doubt xnany of you have read. WhiIe these views are not set down with tbis province speciîïcaily in min& as it was written before this present study was undertaken, we as the recognized body to carry on the work of caring for the sick in Saskatchewan await with considerable anticipation the report of fudings and suggestions they will mn~e." The College1s optimism was helped by Sigeristls response to a query by SCPS officials at a HSSC hearing in Saskatoon that coincided with the SCPS annual meeting. Sigerist was asked by a College representative if he supported salaried state medicine. He responded that: he was not committed to a policy of state medicine. Premier Douglas, he said, had already outlined the plan to build health K~V~C~Sfkom existing facilitie~.'~ The Collegels fears were further assuaged by the Premier's banquet address at the final evening of the SCPS convention. Douglas said that : The govemen t... had no wish to maLe all doctors civil servants. There was no reai controvmy between health insurance and state medicine. The govanment believed that health semices, prevmtive and theraptic should be avaiîable to aii people in the province incspective of thcir ability to pay. He could not, he said, set a tued pattern for the method by which this would be catrried out and he was not particularly pre"upied with forcing any parti& technique. The details would be worked out on whatever basis the government could get possible CO-operationwith the medicai profession.n Indeed, throughout the formative 1944-45 period, Premier Douglas repeatedly dismissed any suggestions that his government intended to introduce a medical care scheme with al1 doctors on salary. It is worth noting here that the transcripts of the HSSC public hearings and tour of the province indicate that Sigerist was made aware of the fact that the province's salaried municipal doctors were also private practitioners: On the way hmSiasbourg to Wadena the Members of the Commission stopped at Wynyard and there had a conversation with Dr. K.M. Polec. Dr. Polec and Dr. Brawley of Wynyard share in a municipal contract for the area and each has a private practice beside~.'~ He was also informed of the municipal doctorsf preference for ffs remuneration in a provincial medical services scheme. Dr. R. K. Johnston told the commission that they "would go on a fee-for-service if Health Insurance cornes in. "'' Report of the Commissioner, H. E. Sigerist The HSSC received its final submission on September 28, 1944, in Regina. As noted in Chapter 3, the representations revealed support in Saskatchewan for the establishment of a salaried medical service. However, this support was not reflected in the HSSC's Report of the Commissioner, submitted October 4, 1944. Dr. Sigeristts report was, in the main, a health care plan for rural Saskatchewan. The provincets urban centres were discussed only briefly, beginning with an introductory statement that "the problem of providing health services to the inhabitants of the cities is less difficult and les8 urgent than the problem of rural health services.nn0 Reference was made to the various medical services plans in the cities, including MSI, and the "great benefits" they provided to those involved. Regarding cities, the report concluded: at the moment the most practical policy may be the gradua1 extension of public seMces so as to include matemity care and hospitalization, supplemented by a system of compulsory health insunuice, the details of which would have to be worked out" For rural Saskatchewan, Sigerist recornmended that the municipal doctor system which "has stood the test of time ... should be maintained and developed."" Municipal doctors would provide a general practitioner service in rural health centres. Cases requiring surgery and other specialized work would be treated in District Hospitals where group practise would predominate. Remarking that municipal doctors 'were unques tionably overburdened with work and underpaid, " the report advised the provincial government to set a minimum salary, representing net income, that would increase with years of service according to a scale to be established. Physicians should be granted paid vacations, and, every few years, leave of absence for post-graduate training.a3 These suggestions to improve the conditions of municipal practise were neither new nor unique. Indeed, the introduction of Dr. Collin's proposed mode1 contract would enact al1 of these recomrnendations. Sigerist made no references to the ffs municipal doctor contracts. In the sensitive area of physician remuneration in general, the report States simply that "there can be no doubt that in the future more and more medical personnel will be employed on a salary basis."" The report endorsed the concept of salary remuneration, but did not, as some hoped, put forth an agenda to either place private practitioners on salary or recommend the termination of the ifs municipal doctor contracts. Nor did it advise that salaried municipal doctors be denied private practice privileges. A number of observations concerning the Dr Sigerist's report can be made. First, David Naylor in Private Practise & Public Payment, As a medical observer later remarked: "It is much milder than might have been expected fiom one known to be such an enthusiastic advocate of the Russian ~~stcm."'~ One might add the following to Naylor's point. When one considers the statements of both Dr. Sigerist and Premier Douglas in September 1944, the rather moderate health care plan put forward by the HSSC Commissioner was probably neither unforeseen, nor unexpected by Saskatchewan residents. Second, the health care plan outlined in the HSSC report was almost identical to that envisaged by the Saskatchewan CCF leadership since the 1930's. Dr. Sigerist's recommendations can be found almost verbatim in the 1937 CCF Hancibook, the 1943-1944 CCF health care plank, Dr. Hugh MacLean8s address of July 1944, and in T. C. Douglas' policy statements as Premier and Minister of Public Health in the autumn of 1944. Thus the Sigerist report should be considered as a continuation and confirmation of previous CCF health care policies. Third, the report's findings and proposals also reflected the policy papers, briefs and petitions of SM,UFCSS, SIiML(minus their demand that doctors be placed on salary) and many more organizations and individuals. Moreover, many of these same ideas were also recommended and supported by the SCPS. As Mombourquette notes: "What was unique about the report was that this was the first time the ideas were presented in a comprehensive package to a government which had the political will to put the reforms into effect."'= The Establishment of the Health Services Planning Commission Following Dr. Sigerist's departure, Dr. M. Sheps and T. H. ~cLeod set to work drafting legislation that the Premier declared would "fulfil the spirit of the [HSSC] report." The Health Services Act became law on November 10, 1944. This Act authorized: 1) the division of the province into health regions "for the administration of health services under the Act and the Public Health Act"; 2) public payment of health senrices "in any health region" and 'for such persons or such class or classes of persons as may be designated by the Lieutenant- Governor in Council"; and 3) the distribution of "grants or subsidies to municipalities, hospital boards and health regions, or any of them for the provision and operation of health service^."^' The Health Services Act of November 1944 also created the Health Services Planning Commission(HSPC) . The commission's broad mandate included the following tasks to facilitate the establishment of a province-wide health senrices scheme as outlined in the HSSC report: 1) determine the costs of providing health services and recomrnend ways of financing and implernenting them; 2) work out in detail a complete health care plan, including financing, for one or more health regions; 3) plan a compulsory health insurance programme for one or more urban centres; 4) and recommend remedial action for municipalities which do not have adequate health services.B8 These tasks, as was the establishment of the Commission itself, were among Sigerist's "recommendations for immediate action.wagThe legislation also authorizcd the appointment of an advisory cornmittee to the HSPC." Dr. Mindel C. Sheps, Mr. T. H. McLtod and Mr. C. C. Gibson were appointed to the HSPC via an Order in Council approved and ordered on November 14, 1944." This small group became the nucleus of both planning and administration of medical and hospital services during the Douglas government's first term in office. Following the creation of the HSPC, Dr. Mindel C. Sheps and Mr. T. H. McLeod started work on health care proposals for rural Saskatchewan. The HSPC completed its "Report on Regional Health Services: A Proposed Plan" on February 15, 1945. An Advisory Committee of the Health Services Planning Commission, representing professional and occupational groups, institutions, labour and women's groups was then established to consider the Commission's proposal. The first meeting of HSPC Advisory Committee convened on March 2, 1945. An examination of Saskatchewan CCF health care policy from 1937 until the party became the government of Saskatchewan in July of 1944 suggests that it was never explicitly comitted to the establishment of a state salaried medical service. The CCF appears to have been undecided as to how physicians would be paid in a provincial medical services plan when it assumed office. The 1943-1944 CCF health care policy stated that a CCF government would seek the CO-operation of the medical profession in developing a provincial medical services plan. This pledge was reiterated with considerable emphasis in Dr. Hugh MacLean's address to the 1944 CCF provincial convention. In power, Premier T. C. Douglas repeatedly denied that his government planned to place physicians on salary. He declared that it was the governmentls policy to provide medical services to al1 the people regardless of their ability to pay - the method by which this was to be accomplished was not important. Moreover, this objective was to be obtained with the CO-operation of the medical profession. One may suggest that, in view of the SCPSI ardent opposition to alternative remuneration systems, the pursuit and maintenance of governrnent-SCPS CO-operation would inevitably result in ffs schemes. These declared policies were followed in securing a medical care plan for old age pensioners and other social assistance beneficiaries. The outcome and negotiations for the Old Age Pensioners(O.~.P) scheme suggests that the CCF8s chief aim was the provision of publicly- funded medical services to the people of Saskatchewan. The method of payment for these medical services, whether fis, sala~y,or capitation, was negotiable. Owing to the Collegels adamant opposition to czpitation and salary remuneration, for the government to insist upon either of these payment methods, would have, without a doubt, retarded the introduction of medical services under a state-controlled plan. A hard-line position on physician remuneration would have led to protracted negotiations, or the difficult and risk-prone option of by- passing the College and attempting to directly force the profession into a salaried medical service. It would appear that neither of these scenarios was agreeable to the Douglas government. Indeed, McLeod and McLeod state that "to the distress of his socialist supporters, Douglas declined to force the doctors on to a salary system in the mid-1940's because he wanted to get his health program for the poor off to a quick start .m92 The 0.A.P agreement, with its inclusion of ifs payment, is the first tangible manifestation(bey0nd both public and private statements) that the Douglas government was committed to a policy of CO-operation with the medical profession in developing a medical care programme for the province. The old-age pension scheme provided the SCPS with a vehicle with which it could work toward the entrenchment of ffs in the province's fledgling etate-financed medical care system. Xndeed, College officiais recognized the 0.A.P scheme as just such an opportunity, as a memo drafted by Dr. B. C. Leech(Chairman of the Collegeus Medical Cornmittee responsible for administering 0.A.P medical service payments to participating physicians) makes clear: The organked profession has undertaken through the OAP.scheme to prove conclusively that a fee for service basis of payment for medical care can operate and be adequate for beneficiaries and fair and satisfactory to both govement(or contracting party) and al1 mernbers of the profession who take pari.93 Preservation of the ifs remuneration system was, without a doubt, an impetus behind the SCPSI complrte CO-operation with the O.A.P. scheme, which became fully operational on January 1, 1945. In the 0.A.P schemets inaugural year, College officials made repeated calls for full compliance with the programme's administrative practices, such as the following that appeared in the May 1945 issue of the Saskatchewan Medical Quarterly: There are still a few doctors who are refushg to CO-operatewith the old-age pension scheme and offer as an excuse "irksome fomm... The proponents of state medicine have always used as an argument, that the salaricd dwtor would not be bothered with bookkeeping and fonn filling so tbt those who would have Health Insurance, voluntary or compulsory, must be prepared for a certain amount of fom filing. The cornmittee would again ask for your co- ~peration.~' The significance of Douglas' acceptance of ffs payment and the O.A.P. scheme per se has not always been fully recognized. The appointment of Henry Sigerist clearly was not part of a CCF strategy to implement a state salaried medical service in Saskatchewan. Sigerist did not advocate the establishment of a salaried service during his health survey of Saskatchewan in the autumn of 1944. Nor did he recommend or set forth a plan for such a medical care system in his report to the provincial government. However, following Sigeristts departure, the HSPC would devise and present to the government and representatives of the public and the SCPS proposals for the developrnent of a province-wide salaried general practitioner service in rural Saskatchewan - despite the fact that Premier Douglas appears to have already dismissed such a policy. Endnotes: 1 Lipset, Agrarian Socialism, op. cit., p. 289; Rands, PnM'lege and Policy, op. cir., p. 98. 2 Saskatchewan Archives Board, Saskatoon (hereafler SABS), Papers of Dr. Hugh MacLean (hereafter MacLean Papers), file 2, "Radio Address by Dr. Hugh MacLean, Vice President, C.C.F. SASK. Section, Wednesday, March 17, 1937," pp. 2,4; "Health Services., Women's Fann Organization. By Dr. Hugh MacLean., Wednes&y June 2, 1937," pp. 5,lO. Lipset, supra, p. 289 a ibid., p. 288. Ibid. ' Rands, supra, p. 98. SABS, MacLean Papers, hle 2, "Radio Address by Dr. Hugh MacLean," p. 3. Ibid; Lipset, supra, p. 289. Ibid. 'O Ibid. 1 I Naylor, Private Practice, Public Payment, op. cit., p.123; Rands, supra, pp. 98-99. " Se+ for example, "Minutes of Sixth Annual Convention of C.C. F. Saskatchewan Section held in The Bessborough Hotel, Saskatoon, July 17- 18, 1941, Resolutions: m."SABS, Papers of the Co-operative Commonwealth Federation, Saskatchewan Section (hereafler CCF Papers), Minute Book #2, p. 7 (#629). " Saskatchewan Archives Board, Regina (hercaftcr SABR), Political Pamphlets, file 19, #4 1, IlThe CCF Program for Saskatchewan," fmt printing, November, 1943, reprinted, April 1944, pp. 7-8; file 19, "Let There Be No Blackout Of Health," circa 1943- 1944; "The CCF Plans For Health," Regina Leader, 12 June 1944. " Ibid. 15 See for exarnple, "Political Parties Outline Stance," Leader Post, 20 May 1944. l6 SABS, CCF Papers, Minute Book #3., '*Resolutionon Health Services," pp. 13 - 14 (#749-750). l7 Ibid. 18 McLeod and McLeod, Tommy Douglas, op. cit., p. 148. '' See for example, The CCF Plans For Health," Leader Post, 12 huie 1944. 20 Lipseî, supra, p. 289; Raads, "The CCF in Saskatchewan" in Donald C. Kerr ed Western Canadian Poiitics, op. cit., p. 6 1. "McLeod and McLeod, supra, p. 127. -- " See for example, P. G. Makam& "The Municipal Doctor, Health Insurance, Co-operative Innulnce And merAlternatives," radio address delivered over CJRM and CFQC, February 2 1, 1943, cited in State Hospital And Medical League, The Case For Smte Medicine (1944), pp. 23-26. 23 SABR, Records of the Health Services Swey Commission (ùereafler HSSC), file 10, Fred Gordon (Secreîaq CCF Saskatoon Constituetify) to the Semtary (Mindel C. Sheps) Dr. Sigerist Health Commission, 16 September 1944. SABR, Politicai Pamphlets, "The CCF Program for Saskatchewau," p. 7. " Raymond Merle Sherdahl, f'The Saskatchewan General Election of 1944," (Unpublished Master's Thesis, University of Saskatchewan, 1966), pp. 72,82. 26 "The CCF Plans For Health," Leader Post, 12 June 1944. '7 Ibid. Ibid. 29 SABR, Political Pamphlets, "The CCF Program for Saskatchewan," pp. 7-8. "The CCF Plans For Health," Leader Post, 12 June 1944; "Political Parties Outhe Stance," Leader Post, 20 May 1944. '' Duffm and Falk, "Sigerist in Saskatchewan," op. cit., p. 672; See also Duffip "The Guru and the Godfather," op. cit., pp. 203-208. 33 SABS, MacLean Papm fde 2, "An Address on Medical Health Senrices by Dr. Hugh MacLean At the C.C.F.Convention, Regina, Saskatchewan July 13, 1944," p. 4. 34 Ibid., p. 3. 35 Ibid., p. 4. 36 Ibid. 37 SABS, MacLean Papers, file 3, "Premier Douglas Becomes Minister of Health," n. d. 38 Malcolm G. Taylor, Health Insurance and Canadian Public Policy, op. cit., p. 87. 39~~anMason Chesney Medical Archives of the Johns Hopkins Medical Institutions, Henry Sigerist Papers, Box 25, Mindel C. Sheps to Henry E. Sigerist, 12 August 1944. Duffm, "The Guru and the Godfather," supra, pp. 195-196. " McLeod and McLeod, supra, p. 147. '' Taylor, supra, p. 88. " SABS, MacLean Papcrs, fiie 29, T. C. Douglas to Dr. Hugh MacLeau, 7 August 1941. " Sigerist made his first field sweyof the Soviet health care system in 1935, rctuming in 1936 for mer study. His findings were pubkhed in 1937 under the title Socialired Medicine in the Soviet Union. In ordcr to keep up with developments, Dr. Sigerist made a tûird trip to the Soviet Union m 1938. in 1943 he founded the American Review of Soviet Medicine. Henry Sigerist, Medicine and Health in the Soviet Union (New York: The Citadel Ress, 1947), pp. xü-xiii; Duflb, "The Gu.and the Godfather," supra, p. 2 12 (n. #6). 4s For an account of Henxy Sigerist's tbree trips to Canada in 1941, 1943, and 1944 prior to his Saskatchewan survey see Duffin and Falk, "Sigerist in Saskatchewan," supra, pp. 660-667; Duffrn, 'The Gwu and the Godfather," supra. pp. 194 - 195. 46 Xbid. 47 Duffm and Falk, "Sigerist in Saskatchewan," supra, p. 670. Due'The Guru and the Godfather,,"supra, p. 195. 48 Hemy E. Sigerist, "Medical Care for Al1 the People," Canadian Journal of Public Health. Vol. 35, NO. 7 (July, 1944), pp. 259-260. 49 SABR,HSSC, file 30, "Relevant Material in Proceedings of Select Special Committee on Social SeCUfity and Health Services,"(unpagitlated). 50 Jacalyn Duffm, "The Guru and the Godfather," supra, p. 196. 5 1 SABS, MacLean Papers, file 12, Dr. Hugh MacLean to T. C. Douglas, 2 August 1944. " SABS, MacLean Papen, fde 29, MacLean to Dr. Sigerist CO. Premier Douglas, 3 October 1944. 53 SABS, MacLean Papers, file 29, MacLean to Dr. Harold Graham, 6 December 1948. 54 Dr. J.F.C. Anderson, "Summary of Pian For Socialized Health Services," Saskatchewan Medical Quarterly (SMQ), Vol. 9, No. 1 (May, 1945), p. 6. 55 SABS, MacLean Papers, füe 12, MacLean to Douglas, 11 August 1944. 56 SMQ ,Vol. 8, No. 3 (September, 1944), p. 12. Ibid. SB SMNSCPS, fde "Health Insurance Miscelianeous," Chairman Divisional Advisory Committee to Dr. T. C. Routley, 1 August 1944. 59 SMQ, Vol. 8, No. 3 (September, 1944), p. 12. SMQ, Vol. 8, No. 4 (December, 1944), p. 9. 6 1 Ibid., p. 8. 62 Ibid., p. 9. 63 It would appear that the * dinmnces in their ideological appmaches, noted by Taylor, concemed the following heated exchange recallcd by Dr. C. J. Houston, I'ath~than opposing ideas on physician remuneration: I11 suppose we had criticized him for king doctrhh and unaware of the truc health needs of the people as we dbctors wm. In rcply he was pretty cutting about the ignorance of doctors on health insurance mattcrs. We rcplicd that we thought we werc infomtd. He said he had secn no evidcnce of it. We ceplied by invithg him to come and be infomed! He was fiuious. But 1 think it a rneasure of the man that he repiied 'AU right, 1 have another meeting now but I'U come back tonight at 7 O'clock.' And he --- did... the hnework of the mechanics of the old age pensioners pian was agreed upon that evening in a fcw short ho un...."SABS, Papers of Dr. C. J. Houston (bereafter Houston Papen), file 23, C. J. Houston to Malcolm G. Taylor, 25 February 1945- 64 TayIor, supra, p. 244. 65 SMQ, Vol. 8, No. 2 (June, 1940), pp. 19-20 66 McLeod and McLeod, supra, p. 149. 67 SABS, Houston Papers, file 23, C. J. Houston to Malcolm G. Taylor, 25 Febnrary 1945. 69 Taylor, supra, p.244. 70 O.C. 1013144. The Saskatchewan Gazette, No. 17, p. 3. 7 1 "Organized Medicine: Amy plan should be applied to Civiliuis," Leader Post, 7 September 1944. 72 Ibid. 73 "Doctors will not be civil servants," Leader Post, 14 September 1944. 74 Nora Sigerist Beeson, Hênry E. Sigerist Autobiographical Wfitings (Montreal: McGill University Press, 1966), p. 189. 7 5 SMQ,, Vol. 8, No. 4 (December, p. 6. 76 "Wide Range of Proposais Heard By Sask. Health Service Survey," Western Producer, 28 September 1944. 77 "Adequate Health Service For AU The People is C.C.F.Ain," WesmProducer, 28 September 1944. 78 SABR, HSSC, fde 27, "Report of Sitting held at Strasbourg, Sask. Sept. 13, 1944 at 10.30 am. in the Town Hall." l9 SABR, HSSC, file 27, "Report of Hearing in Eston, Septemk 21, 1944.," p. 3. 80 Henry E. Sigecist, Saskatchewan Health Services Survey Commission: Repon of the Commissioner, (Regina: Kings Printer, 1944), p. 6. " Ibid. Ibid., p. 5. 83 Ibid. '' Ibid. p. 10. ES Naylor, supra, p. 138. Duane John Mombourquette, "A Govcmmmt and He& Cm: The Co-operative Commonwealth Federation in Saskatchewan," (ünpublished Master's Thesis, University of Regina, 1!NO), p. 55. " Bill 58 - An Act respecthg the Provision of Heaith Services; Health Senfices Act, 1944. Ibid. 89 Sigerist, Report of the Commissioner, supra, p. 12. 90 Biii 58 - An act respecting the Provision of Health Services; Health Services Act. 1944. 9' O.C. 13 16/44. 92 McLeod and McLeod, supra, p. 198. 93 SMNSCPS, file "0.A.P Administration, 1944,"Dr. B. C. Leech, "O. A. P. etc. Scheme," n. d. 94 SMQ, Vol. 9, No. I (May, 1945), pp. 3 1-32. Chapter 5 The Rejection of the 1945 HSPC Salaried Medical Service Proposals Introduction In early 1945 the HSPC completed its health care proposals for rural Saskatchewan. Central to these proposals was a recommendation for the establishment of a salaried general practitioner service. This chapter begins with a brief description of these health care plans, paying close attention to their proposed implementation. Public and organized medicine's receptivity to the HSPC proposals is then detailed. Each departure from the HSPC plans for a salaried medical service is in turn analyzed, including the establishment of the Swift Current medical care plan. Public reaction to ffs remuneration in this experimental health insurance programme is detailed as a further test of Lipset's contention that the Saskatchewan electorate did not support the establishment of salaried medical service. The development and extension of the municipal doctor system under the Douglas government is explored to determine if this initiative was the first step of a strategy to implement a salaried service at a later date. 1945 Health SeMces Planning Commission Rural Health Care Proposals The HSPC rural health care proposals were set out in a series of policy mernoranda prepared for the Minister of public Health titled "Regional Health Services," and in an abridged version of these documents submitted February 15, 1945, as a "Report on Regional Health Services: A Proposed plan."' These papers recommended four main policies: regional organization, local control and autonomy, group practice and diagnostic centres, and, most importantly, a salaried general practitioner service.2 The HSPC recommended that the "general practitioner service should be a salaried service,"' built upon the existing municipal doctor system. General practitioners would be stationed in local health centres serving the population of one or more rural municipalities and the towns and villages therein. The HSPC proposed mode1 contract for the employment of general practitioners by the proposed health boards stipulated that physicians carry out al1 medical and obstetrical work, act as a public health officer, and submit regular reports to the lay health boards. In keeping with salaried service, the physician would 'not conduct any private practice except in an emergency or until another physician is called."' In addition to his salary, graded according to experience, qualifications, responsibility and working conditions, physicians would be provided with a pension plan, paid holidays, and paid leave for post-graduate study, as well as a well- equipped, xent-free office. They would also have the right to appeal dismissal by the local health board and request transfer.' The immediate provision of a medical and hospital service without charge to the patient in ~ralSaskatchewan as envisaged by the HSPC was irnpeded by two factors. First, such an ambitious project would "necessitate substantial contributions by the Federal ~overnment."~ Second, in 1945 Saskatchewan severely lacked the required facilities (hospitals, nursing homes, etc.) ,' modem diagnostic and treatment equipment, and al1 types of health care personnel (technicians, nurses, specialists and in particular general practitioners)' to deliver the high standard of service the HSPC envisaged in every area of the province. In 1946 Premier Douglas noted that: even if Saskatchewan had %20,000,000available to spend on a heahh scheme, we could not have instituted a complete health program because of -tient equipment and trained persomc1.P The HSPC believed that alleviating the shortages of facilities and trained personnel, as opposed to removing the direct cost of hospital and medical care to the citizen of Saskatchewan, should be the province's first priority "since the economic status of the people has improved to a degree, while qualified personnel has become less adequate in numbers."1° The provincial government would follow the advice of its health planners and direct most of its health care budget towards hospital construction, the expansion and modernization of existing health care facilities, the procurement of equipment, the training of nurses, mid-wives, laboratory and X-Ray technicians, and the construction and staffing of a medical school," as opposed to assuming, or substantially subsidizing, the costs of providing hospital and medical services to the people of Saskatchewan. The HSPC hoped that at least one region would be set up in 1945 with a complete hospital and medical service as an experiment. Other regions would be encouxaged to organize in order to CO-ordinate and plan existing and projected health care facilities and services. Until there were adequate personnel and facilities for al1 the regions to provide a complete health service, the HSPC recommended that every resident of rural Saskatchewan be provided with a farnily physician, and that the cost of the doctorfs services be shared by the community served by the physician.12 In order to provide general medical care to al1 the residents of rural Saskatchewan, the HSPC proposed the creation of a financial assistance programme to enable and encourage municipal councils to employ general practitioners on a salary basis, i.e. hire municipal doctors - as the CCF promised during the 1944 provincial election campaign. ~qualizationgrants would be made available to the poorer and less populous municipalities. A flat grant was also recornrnended in order to "induce the more prosperous rural municipalities to enter the scheme."13 Zt was through these grant-in-aids that the HSPC hoped to develop and extend the existing municipal doctor plans into a "province-wide, salaried general practitioner service ...outside the eight cities, as a minimum and a foundation," and "lay the groundwork for a complete regional service."" If the entire rural and small urban population of the province took advantage of these grants, an expenditure of $475,000 would be required. The HSPC estimated that no more than $1508000 to $200,000 would be necessary in the first year as it would be 'some time before the whole population would take advantage" of the grants.15 Meeting of the Advisory Cornmittee to the Health Service Planning Commission, March, 2-3, 1945 Once the HSPC proposals for rural health care were completed, the provincial government hurriedly appointed an advisory cornmittee to the commission, as authorized by the 1944 Health Services Act. The advisory cornmittee's functions were to: a) convey the opinions of their groups with respect to the plans presented to them; b) interpret the governrnentls plans to their organizations; c) form sub-committees on matters of particular interest to certain groups; and dl "suggest plans and subjects for investigation."16 Ultimately cornprised of 31 members, the HSPC Advisory Committee consisted of representatives of the province's medical and para-medical associations, trade unions, agriculture organizations, the Saskatchewan Association of Rural Municipalities(SARM), and a number of private citizens and lay bodies interested in health care reform, such as Matt Anderson and the State Hospital and Medical League(SHML) . The Advisory Comrnittee held its first meeting on March 2-3, 1945. The minutes suggest that the HSPC proposals were well received by the Cornmittee's lay representatives. M. S. Anderson, for example, was particularly supportive of the plan: Mr. M. S. Anderson thought the plan very good, and suggested that the quickest way to sel1 the plan would be for the Government to give srna11 financial assistance to areas already organized He was pleased by the stress place on local responsibility. He was sure that with the feeling among the people and the Goveniment we have now, it will not be long before we have the plan in operation ....17 Moreover, the Advisory Contmittee passed a motion put forward by Mr. J- A. Thain of Saskatoon, representative of the Provincial Council of Trades and Labour Congress, that the HSPC "advise the Government to proceed with the necessary organization to set up at least one region in the very near future ."la According to the minutes, the lay members' sole objection to the proposals concerned the decentralization of medical personnel and facilities, and in particular the concept of having specialists travelling to outlying hospitals to attend patients. Lay delegates concurred with the Cornmittee's medical and dental representatives that it would be far more practical and efficient if specialists were stationary, working al1 the the; patients should be brought to the specialists at the regional centres. There is no evidence in the minutes of lay opposition to the establishment of a salaried general practitionex service.lg The SCPS representatives on the Advisory Comrnittee, Dr. J. F. C. Anderson and Dr. C. J. Houston, did not share their lay counterpartst enthusiasm for the proposals. Dr. Anderson had reservations concerning the proposed administration of the medical service, stating that "too much local interference is not good, if the local Board has too much control over the do~tor."~~The physicians also disagreed with the decentralization proposal. Regarding the proposed salaxied general practitioner service, however, the college representatives were more guarded in their criticism," Dr. Houston merely stated that "conditions under which services are to be rendered should be discussed with those rendering services."22 Directly following Dr. Houstonus statement, Mr. Ansell, representative of the Local Unions of the canadian ~rotherhood of Railway Employees, "suggested that eventually the whole medical service would be a salaried service-"23 Subsequently, Drs. Anderson and Houston "vigorously protested a vote being taken on the acceptability of the plan."" However, J. A. Thain of the Trades and Labour Council "urged with success that the cornmittee shculd endorse the plan before it adjourned in order that progress in implementing it would be possible."25 It is important to note here, however, that according to Dr. C. J. Houston's report to SCPS on the Advisory Cornmittee meeting of March 2-3, 1945, "Douglas had been prcsent at various times and had stated once that the "Commission~splan was not necessarily the policy of the government."26 Dr. Anderson stated that "he had not the authority to endorse any plan now, but would take the plan back to the College and they would be prepared to comment in detailSw2'Accordingly, a meeting with Premier Douglas and the Deputy Minister of Health, Dr. Harnes, was requested by the College and scheduled for March 21, 1945.'' By that time, the provincial government had announced its plans to introduce the HSPC proposed grants scheme, including a flat per- capita grant. In an address to a SARM meeting on March 7, 1945, Premier Douglas stated that grants would be given to rural communities employing municipal doctors provided that their contracts met certain condition^.^^ The SCPS objected to making the grants dependent upon the municipal doctors being restricted £rom engaging in private practice, as recommended by the HSPC. College officiais predicted mdissensionn by the province's municipal doctors if they were denied their private practice privileges and confined to a straight salary.)' Indeed, in his report to the Collegets Central Health Insurance Committee on the HSPC Advisory Committee meeting of March 2, 1945, Dr. C. J. Houston suggested that the province's municipal doctors might leave rural Saskatchewan 'if they are to be restricted entirely to contract pra~tice."~'Consequently, the governmentls medical care grant scherne and the proposed salary municipal doctor contract would be at the forefront of the grievances put forward by SCPS Health Insurance Committee at its meeting with Premier Douglas on March 21, 1945. Meeting of the Central Health Insurance Committee and T. C. Douglas, March 21, 1945. At the outset of the Premier's meeting with the SCPS Central Health Services Cornmittee in the afternoon of Mareh 21, 1945, Douglas was presented with a lengthy resolution that stated the Collegels opposition to "an exclusively salaried service," and reiterated its support for "state-aided health insurance on a fee-for-service ba~is."~' According to the Saskatchewan Medical Quarterly, the ensuing discussion hinged around the following points in particular: (a) Whether Mr. Douglas and his Governent intended a salaried service medical service only?... (b) The necessity for flat gram and their possible abuse. (c) The administrative set- up? In terms of the latter issue, the College was opposed to the Department of Health administering rnedical services. The SCPS wanted the administration to be vested in an independent, non-political Commission with "adequate" representation of the rnedical profes~ion.~'In addition, the SCPS noted that there were no provisions for medical representation on the proposed local, district and regional healtb boards. The doctors were opposed to the nteacher-schoolboard relationship" that would result from such an arrangement." Moreover, as Taylor observed, "if regional boards negotiated contracts with regional medical societies, the political control by the College of the system as a whole would have been seriously fragrr~ented."~~ In response to these concerns, Douglas first stated "that the profession was unduly alarmed and reading intentions into the draft that were not there."17 His "concern was to provide medical care to everyone as rapidly as possible."'' He then reiterated his position from the outset of the Sigerist Conunission that the method by which medical services were to be provided did not matter, just as long as this objective was attained. The governmentts policy was to provide state- aided health insurance in the cities and municipal doctor scheme in the rural areas, "and it was his opinion that such would still leave a very large place for private practi~e."~~Finally, Premier Douglas stated categorically that the government was not committed to the establishment of a salaried medical service: Dr. Hazen asked whether or not his govenunent was definitely and irrevocably committed to salaried state medicine, to which the Premier replied defkitely tbat it was not? Next , regarding the proposed administration, Douglas stated that an independent commission was not possible because the disbursement of tax dollars must be under a government department directly responsible to the people; the local health units were for the purpose of getting people interested in health problems not to "embarrass the doctor by making him responsible to a Local Health Board.8841 In terms of the grant-in-aid scheme for the financing of municipal doctor plans, Douglas made a significant concession to the doctorst insistence on ffs remuneration that would severely compromise the HSPC proposals for the establishment of salaried medical service: He[Douglas] led the meeting to believe that he was willing to subsiâize nual municipalities on a fee-for-service basis as well as those nual municipalities employing municipal doctors on the salary syste~n.'~ The College accepted salary remuneration and the provision of equalization grants in the remote, less prosperous regions of rural Saskatchewan, but insisted on ffs outside of these areas.4"ccordingly, Dr. Houston protested the provision of flat grants, maintaining that they would force municipalities to establish a municipal scheme "regardless as to whether it was in the patientst best interests or applicable to the community's greatest need ...."" The doctors were opposed to grants "which could or might be used as a means of coercion to force a salaried system of medicine in rural areas."4s The Premier was warned that the HSPC proposals would deter physicians from setting up practice in the province and cause others to leave because the 'profession are definitely opposed to converting the medical profession into a salaried branch of local or central government service."46 Regarding the HSPC recommendation to prohibit municipal doctors from private practice, Dr. R. K. Johnston told Douglas that, based on his 1944 survey, the province's municipal doctors wanted a practice of 'contract work[salary]" and "outside practice[private fee-for-service practice for surgical but mainly general medical care rendexed to private patients both within(towns and vil1ages)and outside the contxacting municipality]" (as noted in the SMQ, "not municipal practice aloneU4'), and that "they favoured the municipal woxk as it was now operated. As the meeting came to a close, Douglas "assured" the doctors that a "new[medical carel plan could be worked out based, except in two or three matters, on the general [health insuraneelprinciples adopted at the annual meeting of the College in September 1944."" To this end, the Premier proposed that the Collegets representatives on the Advisory committee, Drs. Anderson, Houston, and Johnston, fonn a sub-committee of the HSPC to "obtain the necessary revis ion^.^^^ This suggestion was enthusiastically received and approved by the SCPS health insurance committee. Hence, it is clear that the Premier rejected the HSPC recommendations for salaried state medicine. Negotiations between the government and the SCPS resumed on Apriï 14, 1945. Drs. Anderson, Houston and Johnston, as the HSPC Advisory Cornittee's newly-appointed medical subcornrnittee, met with the HSPC and Dr. Hames, deputy minister of Public Health, to discuss revisions to the HSPC proposals in accordance with SCPS health insurance principles, as recommended by Premier Douglas. The doctors reiterated their opposition to medical care grants that would "tend to coerce municipalities into adopting a certain kind of scheme."'' They wanted to be certain that such grants would be made available ta municipalities whether physicians were paid by salary or ffs. According to the minutes, 'since they had already been assured of this by the premier, they were assured of it once more."" Aside from these comments, physician remuneration was not discussed. The SCPS committee conceded, with respect to their objections to administration by the Department of Health, that the government must "exercise a certain amount of control" when it "supplies the funds and therefore assumes the resp~nsibility."~~They believed that 'it might be possible to work out an agreement satisfactory to the profession" if "matters relating to technical questions" were referred to a medical advisory committee (comprised of physicians recomrnended by the SCPS).S4 As set forth in the SCPS' health insurance principles adopted at the Collegefs 1944 annual convention, one of the 'technical questionsw that the SCPS wished to have referred to a medical advisory committee concerned physician remuneration: (QSubject to cegulations approved by the CoUege of Physicians and Surgeons to secure the rights and conditions of practice of and for physicians under the scheme;" If the Douglas government or the SCPS' coveted independent commission accepted and adhered to the advice of the proposed medical advisory committee on this rnatter regarding physician remuneration, ffs payment would be safeguarded. Fee-for-service remuneration would be fuxther protected if the Douglas government agrced to principle no- 3 of the 1944 SCPS health insurance proposals: (3) The method and amount of remuneration shalI be decided upon by negotiation between the Commission and the CoUege of surgeons.J6 The College delegation requested that the HSPC provide comment on the 1944 SCPS health insurance principles. In due course the SCPS received a memorandum from Dr. M. Sheps consenting to the establishment of a Medical Advisory Cornmittee whose "advice would be considered and normally acceptedm on the various professional, technical and scientific rnatters specified by the SCPS in their 1944 health insurance principles, including clause (f) as noted above." The SCPS then sought ta have the Sheps memorandum officially endorsed by the Premier. A SCPS negotiating comrnittee, comprised of four specialists based in Saskatoon and Regina: Drs. J. L. Brown, J. P. C. Anderson, E. A. MsCusker and U. J. Gareau,'' met with Premier Douglas August 15, 1945. The College delegation re-iterated SCPS opposition to the administration of medical services by the HSPC and demanded that administrative authority, with the exception of finance, be vested in an independent, non-political commission. At the conclusion of the August meeting Douglas requested a memorandum outlining the SCPS position; College officiais were to receive a memorandum in ret~rn.~~ Accordingly, the College sent a memo similar to the list of the health insurance principles adopted at the 1944 SCPS annual meeting and the resolution of July 29, 1945, with the exception of health insurance principle #3 regarding the method and amount of remuneration to be paid physicians. In this document an additional clause was added under the items to be referred to the proposed Independent Commissionls Medical Advisory Committee that, if accepted, would further safeguard ifs remuneration. Fee for-service would thus be protected by two clauses that the Commission would "refer to the Medical Advisory Committee ...and take such action thereon as the Medical Advisory Cornmittee recomrnends": (b) The agreement or arrangement whereunder the profession will provide medical services. (g) Subject to regdations approved by the College of Physicians and Surgeons to secure the rights and conditions of practice of and for physicians under the ~cherne.~~ Correspondence with the SCPS suggests that the Premier's sole caveat with respect to the powers sought by the College for the Medical Advisory Cornmittee and through this body, the College itself, concerned its demand to determine what physicians were eligible to practice under a provincial health care ~cherne-~lAftex another apparently arnicable meeting September 18, 1945,62 Premier Douglas sent his famous letter of September 19, 1945, confirming his acceptance of an independent commission, a medical advisory comrnittee, and the aforernentioned remuneration clauses that, if adhered to, would preserve ffs payment in a provincial medical services plan.63 But whether, with this letter, Premier Douglas had, in fact, both compromised the HSPC proposals, and precluded the establishment of a state salaried medical service in Saskatchewan, is unclear. As Malcolm G. Taylor notes in his Ph.D. dissertation with respect to Douglas' letter of September 19, 1945: the lettcr is somewhat ambiguous and refers to the need for ncontinuing discussionw and to principles which "it would sceri~..have becn agrccd upon." Whethcr the Govemment will constnie these as a cornmitment when the timc cornes to introduce a province-wide plan is ~nclear.~ However, by this juncture several compromises had been made to the 1945 HSPC proposals for a province wide salaried medical service in rural Saskatchewan. It is to these compromises that we now turn. Municipal Contract Practice: April22, 1945 - November 3, 1945 The first deviation from the 1945 HSPC proposals for the implementation of a salaried general practitioner service in rural Saskatchewan was the introduction of a new model salary municipal doctor contract that continued to allow physicians to engage in private practice on a fis basis. The HSPC recommended straight salary municipal doctor contract was rejected at the first meeting of the HSPC and its Advisory Cornmittee's newly-appointed subcommittee on Local Health Services (consisting of Drs. C. J. Houston and R. K. Johnston of the SCPS and lay members Mr. M. S. Anderson of Bulyea and the President of SARM, Mr. W. S. Woods) on April 22, 1945. The existing Health Services Board(HSB) model contract was examined clause by clause. Both the Cornmittee and the governrnent's health planners unanimously agreed to remove Section B of the HSB model contract that stipulated that the municipal doctor was not to engage in private practice outside the confines of his municipality, except in emergency situation^.^^ Clause 3b that set forth the municipal doctor's right to pxivate practice, providing that it did not interfere with his duties to the municipality, was lef t intact.66 At a glance, the decision in early 1945 to continue to allow the province's municipal doctor's to engage in private practice appears as both a major concession to the medical profession and a significant impediment to the establishment of a salaried medical service in rural Saskatchewan. However, if the governrnent's medical care grants scheme engendered a significant expansion of the municipal doctor system as the HSPC anticipated, simultaneously eliminating the rural private rnedical practice market, the municipal doctors' private practice privileges would be of little consequence. As such, a straight salary municipal doctor contract, as recommended by the HSPC, was not essential to the development of a salaried rnedical service in rural Saskatchewan. A copy of the new-mode1 contract and questionnaire were forwarded to al1 municipal physicians on August 9, 1945. According to a report compiled by R. K. Johnston and Dr. C. J. Houston, the replies as of September 12, 1945, indicated that municipal doctors "do favour Municipal Contract Practice and that they are satisfied with the proposed minimum salary of $5000.00 for a 9 township municipality with a population of 2000."~' It is important to emphasize here that this endorsement of municipal contract practice did not indicate a predilection towards salary remuneration among the municipal doctors. At the 1945 SCPS Annual Meeting on September 20-22, 1945, Dr. Johnston "pointed out that the [municipal physicians] prefer fee-for-service contracts."68 Johnston and Houston also reported that the municipal doctors were not generally in favour of surgical contracts, but if necessary preferred ifs agreements.69 One may suggest, in view of the municipal doctors' preference for fis payment, that the municipal physicians' continued support for municipal medicine stemmed, in part, from the fact acknowledged by the HSPC that a "considerable portion of the work of these physicians would be private practice . Fee-for-service contracts were also discussed at the Subcottunittee meeting of April 22, 1945. Dr. M. Sheps viewed a mode1 ffs contract as problematic: Dr. Sheps reported that she had not prepred a model since there were very few such contracts avaiiable in the department, and since it was difficult to see how any control could be exercked over mch contracts without setting up a numbcr of regional medical committces to pass on al1 work done and on all accounts. It was doubdid whether the governrnent could do this in the case of schemes financd and controlIed by local municipal councils. She suggested that al1 îhe Commission could do was to Iay dom certain minimum semices chat was to be provided and leave the rest up to the local people? Dr. Houston insisted that there be a minimum schedule of fees for ffs contracts. Dr. Johnston and the cornmittee's lay representatives felt that 75% of the SCPS 1942 schedule, suggested by Dr. Houston, was too high. The meeting ended with this matter undecided and with the understanding that Dr. Sheps would send the cornmittee members copies of existing ffs contracts.'2 As we shall see, the absence of a model ffs contract became a major source of tension and discord between the SCPS and the HSPC. Having devised a new model salary municipal doctor contract, the HSPC proceeded to prepare regulations for the provision of medical care grants, namely that agreements between municipal councils and physicians conform to the new model contract. As the HSPC set to work on this task it soon became apparent that organized medicine would attempt to deter the creation of a health care system in rural Saskatchewan based on municipal contract practice. In a confidential memo to O. W. Valleau, acting Minister of Health, May 7, 1945, Dr. Sheps reported that Medical Services Incorporated(MS1) was pressuring the council of the rural municipality(RM) of Lajord to cancel its municipal doctor contract(sa1ary) with Dr. Kraminsky of Regina, and enter into an agreement with MSI for al1 its medical ~ervices.'~ Should the municipal council refuse, MSI threatened to cancel its contract with the RM for surgical services and force Dr. Kraminsky to do likewise. MSI had adopted a resolution to the effect that none of its members (al1 members of the Regina District Medical Society were mernbers of this physician-controlled medical insurance body) would enter into a municipal doctor contract. Sheps viewed this incident as the start of an MSI carnpaign municipal contract practice in Saskatchewan: There is no doubt that, while the excitant(sic) cause for this move on the part of Medical Services, Inc., may have been cupidity, tinged with an even worse motive, the main reason is to attack the municipal doctor systea Attacking it in a wealthy municipality cbse to Regina is. they probably feel a good beginning." The Lajord incident emphasized the vulnerability of the government's rural medical care policy to MSX. In order to both preserve and facilitate the expans ion the municipal doctor system and other lay- controlled medical care schemes, in 1946 the government would remove In another initiative to avert the development of a province-wide municipal doctor system outside of the cities, the SCPS sought changes to the government's forthcoming grants for municipal medical care schemes. In a letter to Dr Mindel Sheps of May 10, 1945, Dr. C. J. Houston rnaintained that many of the rural municipalities eligible for equalization grants were receiving an excellent medical service from several private practitioners that was superior to one whereby residents would be tied to one municipal doctor. The sums involved in the proposed grants, which Houston referred to as excessive "bribes" that would ucoerce any municipality into providing municipal doctors regardless of whether it is in the best interests of the patients ~oncerned,"'~could thus be better utilized obtaining other health services urgently required in these areas, e.g. hospitals, nursing homes, etc. He therefore recommended that the grants be made applicable towards the costs of a variety health services, as opposed to the exclusive use of employing municipal doctors." Dr. M. Sheps replied that the "general purpose and types of grants available ...." were not HSPC recomrnendations, but na result of the decision of the government;" and as such, the commission was not in the position to discuss any alteration to the grants.'' The Deputy Minister of Health, Dr. Hames, wrote to Dr. Houston stating his concurrence with Dr Sheps' reply and that 'a change in policy will not be Subsequently, on June 12, 1945, an order in council was passed that authorized the provision of flat grants and equalization grants to assist municipal councils in financing medical services plans.B0 As such, the provincial government introduced its medical care grants scheme for the employment of municipal physicians despite SCPS opposition. ft is worth noting here that there was little that the College could do to stop this initiative. The municipal doctor system was a popular institution in rural Saskatchewan. As Premier Douglas reminded the medical profession in an essay published in the May 1945 edition of the Saskatchewan Medical Quarterly: 'no municipality, once having adopted the system has given it up of its own accord.w81 To openly oppose the government's financial assistance programme for the extension of the salaried municipal doctors system would only further damage, by the SCPS' own admission, organized medicine's poor public image.82 In addition, R. K. Johnston, the municipal doctorsf representative on the SCPS Health Insurance Cornmittee, was in accord with flat grants because, one may suggest, they would encourage the inclusion of a minimum salary, holidays, etc., in the municipal contracts of the municipalities not eligible for equalization grants." Having failed in its efforts to alter the government's medical care grants scheme, the SCPS took consolation in the fact that the grants would be available to rural rnunicipalities "whether payment is made by flat ealary, fee-for-service, capitation fees or any combination of the preceding."" Thus Douglas honoured his verbal promise to the SCPS Health Insurance Committee on March 2, 1945, that municipal councils operating ffs medical care schemes would also be eligible for state assistance - the second and, in hindsight, most significant compromise to the 1945 HSPC proposals. Since 1941 rural municipalities had the authority to pay their municipal doctors on a ffs basis. The vast majority of municipal councils, however, continued to renew their annual contracts on a salary basis. As noted in Chapter 2, of the approximately 179 municipal medical care plans in operation in 1944, only 10 schernes recompensed physicians on a ffs basis. Municipal councils appear to have preferred salary to ffs plans because they allowed for accurate budgeting. As long as physicians were willing to work on contract, one could safely estimate that the vast majority of existing and future municipal doctor plans would operate on a salary basis. As such, the possibility of developing a de facto salaried service as envisaged by the HSPC still txisted despite this concession. Moreover, ironically, making the grants available for ffs municipal medical care plans would aid the implementation of the governmentts medical grants scheme - and, in turn, a policy that could potentially lead to the establishment of a province-wide salaried medical service. Because the grant-in-aids were available for ffs as well as salary medical plans the provincial government could dismiss accusations that it was imposing salaried employment of physicians in rural Saskatchewan. For example, in reply to Dr. Houston's contention that the medical care grants would force the employment of municipal doctors, Dr. Mindel Sheps informed Houston that the rural municipalities in his area could devise a scheme whereby they agreed to pay any of the physicians in Yorkton and the surrounding towns on a ffs basis As the spectre of the development of a salaried general practitioner service via the expansion of the municipal doctor system still existed, the SCPS mistrusted the HSPC and wanted to have municipalities establish ffs plans, particularly those that allowed patients to consult doctors anywhere in the province. As Dr. C. J. Houston and R. K. Johnston noted in a SCPS report of August 1945 regarding municipal medical care plans, the ffs plans with free choice of physician "more nearly resembles Our ideal of Health Insurance and should be more easily fitted into a state scheme when it In this context, College officials were concerned by the HSPC's lack of initiative and apparent reluctance to formulate a model ffs contract." The implications of the absence of a model ffs contract in connection with the medical care grants scheme were forcefully stated by C. J. Houston in a letter ta Dr. Lindsay September 26, 1945: The grants to which 1 have so often refmed and which nc other medical men seem to have studied as to their impiications - are the only tangible remainder of Madame Sheps' plan for state medicine. But the regulation and order-in-councils are al1 in existence to apply thern as fiom January 1, 1945 - and the various municipal councils are studying how to get in on them. As it stands, any municipality that wants to get the grant would fmd only one contract officiaUy approved - that is the mode1 municipal physician agreement on a salary basis - and that in spite of the fact that Mr. Douglas has repeatedly stated that grants would be available whether the contract were on salary or fee-for-service basis. We want this made more definite and specific and that the municipalities should be made aware of their entidement to a choice of contract?' Drs. C. J. Houston and R. K. Johnston, whorn the SCPS appointed as a cornmittee to formulate a model ffs contracts for both general practitioner and surgical services on July 25, 1945,a9believed that the apparent lack of initiative on the part of the HSPC to introduce an approved ffs model contract indicated a HSPC policy to encourage the establishment of salary as opposed to fis municipal medical care plans: It appears tbat the govcnunent is corrrmitted to a scheme of prepaid medical care and that they wish to kceand service it on a municipal basis. It would also appear that certain elements within the governent service are anxious to coerce us into one type of salaried medical practice? This conviction stemmed from and contributed to the SCPSI growing distrust of the HSPC and, in particular, Mindel Sheps, the architect of the 1945 HSPC proposals for a salaried medical service, which College officia16 referred to as the "Sheps Dr. Houston would later confide to Dr. Lindsay, following Mindel's resignation from the HSPC in January of 1946, that he: always felt that Sheps' chief objective was to canalize the govcnunent's health efforts inîo channeis that would facilitate a scheme of State Medicine and make the introduction of health insurance more mcuit.92 As the SCPS predicted, the HSPC did not devise a mode1 ffs contract during the surnmer or early autumn of 1945. However, the Commission did issue grants to municipalities with ffs plans during this period. Of the 33 municipal medical care schemes to receive grants between July 1, 1945, and Oct 31, 1945, 5 were on a ffs basis. However, to the consternation of the College 3 of these approved contracts were at 50% the SCPS fee schedule as opposed to the 75% demanded by the doctors. Convinced that the absence of an approved model ffs contract would facilitate the establishment of salaried plans the SCPS once again sent a letter to the HSPC and Premier Douglas demanding that the HSPC devise a model fis contract - this time with a demand that the fees referred to be at 75% the SCPS fee schedule.'= On November 3, 1945, at a meeting requested by the SCPS to discuss 'municipal contract practice" Premier Douglas agreed that the HSPC should draft a model fis contract. Henceforth this issue ceased from being a major source of conflict between the SCPS and the provincial government, although it was not until 1947 that a model ffs contract was introduced. With Mindel Shepso resignation from HSPC in early 1946,95 the SCPSt suspicions that the commission was using the absence of an approved ifs mode1 contract to encourage the establishment of salary as opposed to ffs municipal medical care plans seem to have died. The doctorst concerns with respect to the expansion of the salary municipal doctor system were mitigated further by the inclusion of ffs payment, as opposed to salary, in the Swift Current medical care plan, the province's first experimental medical insurance plan, launched July 1, 1946. This development, moreover, entailed the discontinuation of several salary municipal doctor schemes. The Swift Current Medical Care Programme and Physician Remuneration in Saskatchewan: 1946 - 1949 The incorporation of ffs remuneration in the province's first regional medical care plan - the fourth and final departure from the 1945 HSPC recommendations for a salaried general practitioner service - was the result of local decision making, as opposed to a direct concession to the SCPS by the Douglas govewnment. The particular organization, form and content of medical services in the health regions, including physician remuneration, resided with local governrnent authorities through their elected health board.96 As Dickinson notes, the principles of local control and initiative were institutionalized in the procedures and regulations governing the establishment and powers of health regions and their lay boards, in part, because the provincial governrnent, "firmly rooted at the time in a tradition of agrarian democratic populism, was concerned not to usurp traditional local prerogatives and control over the provision of health care services.ng' These policies, however, led to the most visible departure from the 1945 HSPC salaried medical service proposals because the first area in the province to secure the necessary support to set up a health region and, in turn, decide to introduce a medical services plan, Health Region #1, Swift CunentIg' was the least conducive to the establishment of a salary medical service. Of the 30 rural municipalities, 34 villages, 6 toms and one city that constituted the Swift Current Health Region, only 4-7 rural municipalities and several villages within them had municipal doctor s~hemes.~' And of these municipal medical care plans 3-4 of the schemes were on a ffs ba~is,~'~almost 41 of the approximately 10 ffs plans in operation in 1944-1946.101 Moreover, the senior executive positions of the Swift Current Health Board(Car1 Kjorven board chairman and Stewart Robertson, Secretary Treasurerlwere drawn from these municipalities with ffs plans .'O2 As was W. J. Burak, Secretary Treasurer and former reeve of the Rural Municipality of Pittville, who was instrumental in securing support for both regional organization and the establishment of a medical services plan.''' The area's experience with ffs plans, and its acceptance of ffs remuneration is candidly recorded in the Saska tchewan Medical Quarterly : For some time several municipalities within the region had operated, quite successfiilly, schemes of municipal practice on the basis of freedom of choice of doctor on a fee-for- service rendered basis. The medical men of the region expressed confidence in the members of the regional executive and also believed they had the confidence of the executive.'" As such, the board of the Swift Current Health Health Region(SCHR) did not object when the Swift Current District Medical Society declared that was willing participate medical care plan provided that physicians were paid on a ffs basis and patients had free choice of doctor .los Indeed, the Board's initial overtures to the region's local physicians seem to have included a proposal to pay doctors on a fis basis.lo6 The doctors successfully bargained for ffs payment at 75% the SCPS fee schedule.'O7 Al though the inclusion of f fs remuneration the Swift Current Medical Care plan was not a direct CCF concession to the SCPS as some scholars sugge~t,~~~this departure from the 1945 HSPC recommendations for salaried medicine was facilitated by the Douglas governmentls policy to subsidize both ffs and salary municipal plans facilitated this development .log Moreover, it is important to note that even if the Douglas government had retained control over physician remuneration policy in the health regions, it would appear that a similar deviation from the 1945 HSPC proposals would have occurred. At a meeting with local physicians of the proposed Moose Jaw health region on January 7, 1946, Douglas stated that if the regional board decided to implement a medical services plan, it was probable that doctors would be paid on a ffs basis: Following the talk there was a lengthy discussion period in which the doctors asked specific questions. Chiefly they seemed to be worried about whether or not they would be placed defiaitely on salary and the Premier assured them that any anangements made by the regional board would be on the advice of &eu own medical advisory committee and with the approval of the Health Services PIanning Commission. He suggested that it seemed probably[sic] that should the regional board undertake in the not too distant future to provide free medical senrices that each person in the region would then be given a card that entitled that person to go to the doctors of his choice for services and the doctor wouid then submit his fee to the board. ' 'O In the context of organized medicine's objective, pursued since the early entrench ffs practice provincial medical services the incorporation ffs payment the Swift Current medical care programme was an important victory. However, in 1946 the preservation of ffs medicine in Saskatchewan was far from certain. First, just as the spectre of the establishment of a salaried service in rural Saskatchewan was receding, a new threat to ffs medicine in the province had emerged from the Saskatoon Medical and Hospital Benefit Association. By early 1946, the medical services co- operative had grown to 13, 000 rnembers borrow funds and expand its operations amenciments to its charter by the provi persons, including dependants, were el benefits.ll' The CO-operative anticipat of 1946,lL3 about 1/3 of the city' s app residents. At the CO-operative's annual mee Angus Macpherson, Mayor of Saskatoon, directors had been authorized to borro the construction a group practice clin physicians.'" Satellite operations wo North Battleford and 10 additional lar toms of Rosetown, Unity, Biggar, Mild ~uther1and.l'~The director of the asso the CO-operative was "planning, with G Saskatoon area on a voluntary basis wh originally set out to do."l16 The manager of the medical CO-op maintained that the provincial governm "wished the association to avail itsel university medical centre and hospital association extend its services to mor SCPS registrar, Dr. Lindsay, requested provincial government1s understanding Douglas replied: As you know, the govcmment feels that the necessary step in the development of adequate gratified whenever group practice clinics are set u whenever a group practice clinic is set up in t)iic this is a healthy development and we have no do first year of operation of its fis medical care plan and the health regionrs projected deficits for 1947/1948.lZ5 In reporting SARMts negative response to the 1947 fee-schedule at a SCPS meeting September 6, 1947, College officiais announced that SARM believed that the cost-overruns of the Swift Current ffs medical services plan proved that salary contract offered greater control over expendit~re.'~~They also reported that the rural municipalities were reluctant to accept ffs contracts for fear of being "dragged into a health region."12' Based on a meeting with the SAM executive October 23, 1947, to discuss the SCPS 1947 fee-schedule and related issues HSPC Chairman Dr. F. D. Mott reported that: There is a very strong sentiment among mernbers of the Executive for straight state medicine, with physicians on salary. However, they realize that this kind of deveiopment is not to be anticipated in the immediate fiture and they are reasonably open-minded about using the fee-for-service system as a bais for payments to physicians.'28 On Novernber 1, 1947, SARM informed the College Registrar, Dr R. G. Fergusson, that the 1947 SCPS fee-schedule was acceptable (albeit not at IOO%, the precise percentage would have to be worked out), provided that a 'cost ceiling be establishedw for both municipal and regional medical care plans. '" SARM was also in agreement with the HSPC that the salaried municipal doctor schemes should be strengthened, via adequate salaries and security measures, so that they would not be 'eliminated and replaced by more expensive fee-for-service plans."l3' Fee-for-service medicine in Saskatchewan was also threatened by the fact that the establishment of the Swift Current ifs medical care plan did not rule out the implementation of a salaried medical service in the other health regions, or the Swift Current Health Region at a later date. In areaa of the province where salaried municipal doctor plans were well-entrenched, residents might be less willing to accept a ffs scheme,13' and insist upon alternative remuneration methods - especially in the context of the Swift Current medical care plants previous and projected operating deficit(s). Indeed, at a meeting held December 10, 1947, to discuss expenditure ceilings for regional, municipal, and provincial fis medical care plans, with Premier Douglas, the HSPC, and the SARM medical care committee in attendance, Mr. Kjorven and Mx. Robertson, Chairman and Secretary-Treasurer of the Swift Current Health Region Board, announced that: if the doctors would not agree to a reasonable Limitation on the expenditure of fuiids, the Region was prepared to iastitute a system of medical care with doctors on salary and with ciinics owned and opented by the ~egion."' In this context, despite the objections of the SCPS, participating physicians in the Swift Current medical care programme agreed to a budget ceiling for 1948.'~~ Furthermore, the Douglas government could return to the principles of the original 1945 HSPC proposals - as the supporters of a salaried scheme demanded - and insist on salary remuneration in regional rnedical care schemes. However, it would appear that the provincial government had no intention of utilizing the municipal doctor system as a foundation for the establishment of a salaried medical service. At a HSPC advisory committee meeting on May 9-10, 1947, Commission Chairman Dr. Mott stated that the establishment of regional medical care schemes would "mean wiping out" municipal doctor plans.13' He observed that it might be necessary to provide a special subsidy to retain doctors in the outlying areas of health regions. Dr. Anderson remarked that the SCPS mrecognized the need for salary retainers for doctors in remote areas but in addition doctors should be allowed to collect fees in order to attxact them to outlying areas."13' In this context, Dr. Mott appears to have ignoxed a suggestion(immediate1y attacked by SCPS officials) put forward by T. H. Thain, representative of the Saskatchewan Provincial Executive, The Trades and Labour Congress of Canada, that al1 doctors be placed on ~a1ary.l~~As such, it would appear that the Swift Current medical care plan had established a precedent with respect to physician remuneration in regional medical care schemes. Prior to the meeting of May 1947, T. H. Thain, who had argued with success against the objections of the SCPS that the advisory committee endorse the 1945 HSPC proposals at their unveiling on March 2, 1945, stated at a Trades and Labour Congress meeting that the Douglas government "didn't have the guts' to implement a real scheme of socialized medicine.""' Dr. Mottts comments with respect to regional medical services at the HSPC advisory committee meeting in May of 1947, no doubt, reaffirmed Mr Thain's convictions. Shortly after the May meeting, Mr Thain resigned from the Advisory Cornmittee to the HSPC. The compromises to the 1945 HSPC proposals for the establishment of a salaried medical service appear to have been the primary motivation for his action: Afker two years of continuous erosion of the plan and seeing no hope of having it established under the present systern 1 resigned hmthe Commission in protest of the lack of action to place the main sections of the plan in operation, that of al1 administrators of services under the health services plan to be on a salary basis. 1 was very critical of the government for its lack of fortitude."' Other advocates of a salaried service, both within and outside the CCF expressed their opposition to the ffs medical care plan introduced in the Swift Current health region,"" and urged the provincial government and the regional health boards to hire doctors on salary. The SHML was particularly critical of the Swift Current Health Region's ffs plan, as exemplified by the following excexpt from the editorial in the October 1947 edition of the League1s Health Services Revi ew: The Swift Current health region No. 1. has demonsûated that the financial remto medical personnel on a fee-for-senice basis when paid for by the Region so that people do not refrain fiom secking medical attention is ridicuIously high and out of all reasoa.. We deplore the pussy-footing attitude which bows to the deman& of organized medicine for maintainhg the less efficient method of private p~ïictice."~ The SHML continued to pass resolutions at its annual conventions calling for doctors to be paid on a straight salaried basis .'" The SHML believed that if the government were to employ on a salaried basis al1 physicians willing to practise on salary and made their services available to the public "there would soon be such inroads into private practice that sufficient medical personnel would be available a salary basis ."ld2 Younger doctors and, in particular, recent and forthcoming medical graduates, who were perceived being more agreeable to salary remuneration, were viewed by the SHML as the potential nucleus of a nascent state salaried medical ~enrice."~ Although the provincial government clearly did not intend to force private practitioners into a salaried medical service, it did actively recruit recent top graduates from Canadian medical schools to work in health rcgions and medical centres in Saskatchewan on a salary basis. Selected graduates were offered minimum salaries of $5000 per annum, two weeks annual holiday with pay, and an additional three months every second year for post-graduate work.14' In addition, the HSPC sought to strengthen the salaried municipal doctor plans. The HSPC also pressed the Board of the Swift Current Health Region to establish a group practice clinic with a staff of full-time salaried specialists .145 These initiatives, coupled with the rural municipalitiesv preference for salary as opposed to ffs municipal doctor plans, may have prompted SHML President Dr. Setka to declare at a SARM meeting February 24, 1948, that he was "convinced that the Province was heading rapidly into a salaried medical service.w146 But this was not to be. First, in spite of the initiatives to secure doctors on salary, the provincial government appears to have been agreeable to the continued development of a province-wide health care system on a ifs basis, provided that there was a ceiling on expenditure. In a letter to Dr. G. Gordon Ferguson, College Registrar, February 26, 1949, clarifying the governmentls position on physician remuneration in the ffs medical care plans operated by individual municipalities and health regions, Premier Douglas referred to these fis schemes as the 'forerunners of an over-al1 provincial program to be developed as soon as it is feasible."14' He stated that he was in accord with a policy of paying physicians "adequately and generously for their services," but that such programmes must 'be financially sound" and not 'overtax the paying ability of the people ~oncerned."'~~ The fact that the Douglas government was neithex developing nor planning to implement a salaried medical service in the province, and in contrast, the apparent public support for such a policy was candidly stated in passing by HSPC Chairman F. D. Mott, in a letter to Dr Hugh MacLean dated March 21, 1949: ...the medical profession here simply don? know when they are well off. Sometimes 1 feel like pulling out leaving them to their fate with a population that wants to see real state medicine developed rather than the conservative form of health insurance whicb we are slowly devel~ping.'~~ Second, the anticipated expansion of the predominantly salaried municipal doctors system via the governmentrs medical care grant scheme did not occur, as Dr. C. J. Houston observed in a letter to the Dr. G. Gordon Ferguson in the late 1940's: These grants were in sums out of ail reason & could never be justified except as a whip to encourage the RM Doctor idea. It bas not worked but if timcs get tough it might. We should strive to have these grants made on a diffénmt[basis] ....''O The municipal doctor system grew incrementally until 1947, its peak year with over 210,000 persans covered(about 25% of the population),1Sf when, in the words of a Department of Health official, the "better [rural] practices [had] been taken. Thereafter the municipal doctor system teturned to its average coverage, since 1944, of approximately 200,000 persons, where it remained until the early 1950's.'~' In early 1945 the HSPC unveiled its proposals for the establishment of a salaried general practitioner service in rural Saskatchewan. A salaried service would be developed through a gradua1 extension of the province's existing municipal doctor system via the provision of financial grants and the introduction of a salary municipal doctor contract that prohibited physicians from engaging in private practice . On March 21, 1945, SCPS officiais informed Premier Douglas that the HSPC proposals were unacceptable. The College re-iterated its position that it was opposed to salary-contract arrangements with the exception of axeas where the ffs method could not support and retain the services of a general practitioner. The leader of the province's municipal doctors, R. K. Johnston, protested the imposition of a straight salary municipal doctor contract, pointing out that those physicians presently engaged in municipal medicine desired a practice of municipal contract and private practice. As such, the medical profession was united in opposition to the HSPC plans for the development of the municipal doctor system into a salaried general practitioner service. At this first demonstration of SCPS opposition Premier Douglas clearly rejected the HSPC recommendations for the establishment of a salaried medical service in rural Saskatchewan. The various departures from the 1945 HSPC proposals for salaried general practitioner service followed without any apparent resistance by the HSPC and the Minister of Health, Premier Douglas. First, the HSPC recommended straight salary municipal doctor contract was not implemented (a new mode1 contract was introduced that continued to allow municipal physicians to engage in private practice) . Second, the government's medical care grants were available for both salary and ffs schemes. Third, premier Douglas sent a letter dated September 25, 1945, regardhg the administration of a provincial medical care scheme, that if adhered to would effectively safeguard ffs medicine. Fourth, ffs rather than salary remuneration was incorporated in the Swift Current Health Regionfs medical care plan. The latter deviation from the 1945 HSPC proposals was the result of local decision making, rather than a direct concession to ffs medicine by the Douglas government. In this area of the province where ffs municipal medical plans were well entrenched and popular with the people, the regional board's initial overtures to local physicians appear to have included an offer to pay physicians on a ffs basis. However, the government's policy to subsidize both ffs and salary municipal plans facilitated this development. Moreover, it is important to note that Douglasf Moose Jaw statement of January 7, 1946, suggests that even if the government had retained control over physician remuneration policy in the health regions, a similar departure fxom the 1945 HSPC salaried medical service proposals would have occurred . The provincial government sought to hire doctors on salary, as well as strengthen the salaried municipal doctor plans so that they would not be replaced by ffs schemes. However, it did not attempt nor plan (once the province was in a position to assume the cost of medical senrice) to force doctors into a salaried medical service. The Douglas government was agreeable to the continued development of the province's nascent medical services plan on a fis basis, provided there were ceilings on expenditure. Indeed, it was willing and appears to have supported the replacement of salaried municipal doctor schemes with ifs regional medical care plans. The development and extension of the municipal doctor system under the Douglas government clearly was not part of a strategy to implement a salaried medical service in the future . Aïthough the leadership of the SCPS was opposed to the expansion of the municipal doctor system, it does not appear that it put 'pressure on its members, made it impossible for them to pursue careers as municipal doctors on ~alary."'~~The efforts of the Regina ~istrict Medical Society to pressure a Regina-based general practitioner to discontinue his salary municipal doctor contract with the rural municipality of Lajord in the Spring of 1945 may have been the basis for this assertion by McLeod and McLeod. However, the expansion of doctor-controlled prepayment medical care plans in rural Saskatchewan, beginning in the late 19401s, both reduced the number, and prevented the extension, of the municipal doctor scherne~.~~~In this context, one may suggest that if the CCF had followed the 1945 HSPC recornmendations and provided financial assistance exclusively for salary municipal medical care plans - the municipal medical system would not have been extended into a province-wide salaried medical service in rural Saskatchewan. Public support for the implementation of the 1945 HSPC proposals was not lacking. Indeed, this programme was enthusiastically endorsed by the HSPC advisory cornmittee, which was comprised predominantly of laypersons. The supporters of a salaried service criticized ffs payment in the Swift Current Health Region (SCHR) and urged the government to place doctors on salary. The SCHR budget deficit in its first year of operation, projected further deficits, and the SCPS payment dernands strengthened a conviction in Saskatchewan that doctors should be remunerated on salary basis in a province-wide medical service, as HSPC chairman Dr. Fred Mott observed among the executive of SARM. They also engendered a perception among the rural municipalities that the ffs method was both too expensive and financially unsound, strengthening the rural municipalities' preference for salary medical care plans. By 1947, in an area of the province distinguished by its support for ffs remuneration, the Board of the SCHR was prepared to terminate its ifs medical care plan and implement a scheme with salaried doctors and group practice clinics if the doctors would not accept an expenditure ceiling. Public opinion was clearly conducive to the development of a salaried medical service throughout the 1940's. Endnotes: I Saskatchewan Archives Board, Regina (hereafler SABR), Papers of T. H. McLeodbereafter McLeod Papen], file 46, 'Regional Health Services," December 1944. 2 Saskatchewan Medical Association/Collegeof Physicians and Surgeons of Saskatchewan Archives (hereafter SMABCPS), "Report on Regional Health Services: A Proposed Plan." 3 Ibid., Part 3. Local Health Services, p. 7. ' Ibid., p. 9. Ibid., pp. 7-9. An estimated minimum S 10,000,000 per aunum, in addition to capital expenditure was required for the health care system envisaged by the HSPC; Ibid., Part 2. Principles of Health Services Planning, p. 1. ' The HSPC maintained that the province required an additional 1500 hospital beds to hstits present bed capacity of 2,484 (3.4 per 1000 residents) to 3984 (5 to 5000); Ibid., Part 1. Existing Health Services, p. 10. In March of 1943, thne were 3 1 1 generai practitioners (1 for every 2,882 penons) of which an estimated 113 were over 60 years of age. Outside of the province's eight cities there were 213 physicians (1:3471). TO obtain the HSPC suggested "minimum adequate standard" of 1:2000, the province required an additional 140 general practitioners, plus 75 to replace those near retirement, a simcant number of which were in municipal contract practice. Ibid., Part 1. Existing Health Services, pp. 9-10. '> "Province sets Pace declares Douglas," Leader Post, 16 March 1946. 1 O SWSCPS, "Report on Regional Health Services," p. l(forward). " Duane Mombourquette, "A Govexnment and Health Care: The Co-operative Commonwealth Federation in Saskatchewan, 1944 -1964." (Unpublished Master's Thesis, University of Regina, 1990), pp. 79-80; SMQ, Vol. 9, No. 1 (May, 1945), p. 8. "SWSCPS, "Report on Regional Healîh Services," Part 3. Local Health Se~ces.p. 2; Part 5. hplementation of Plans, p. 6. l3 Ibid., Part 5. Implementation of Plans, p. 2. l4 Ibid., Part 3. Local Health Services, p. 2; SABR, McLeod Papers, file 46, "Regionai Health Services: Memorandum TV, Local Health Services," p. 2 1. 15 SWSCPS, "Report on Regional Health Services," Part 5. Ixnplementation of Plans, pp. 2-3. 16 Ibid., p. 1. l7 SABR, McLeOd Papers, file 1, "Minutes of Meeting of the Advisow Committee, March 2 & 3, 1945," p. 2. 11 Ibid., pp. 6-8. l9 Ibid., p. 7. 'O ibid., p. 5. " A Ietter fiom Dr. Mindel Sheps to Dr. Heiuy Sigerist describing both public and SCPS reaction to the HSPC proposais at the HSPC advisory cornmittee meeting in March of 1945 also contains no mention of physician opposition to the HSPC recomrnendation for a salaned medical service. Alan Mason Chesney Medical Archives of the JobHopb Medical Institutions, Henry Sigerist Papers, Box 25, Mindel Sheps to Henry Sigerist, 8 March 1945. " SABR, McLeod Papen, file 1, "Minutes of Meeting of the Advisory Committee, March 2 & 3,1945," p. 8. 23 Ibid., pp. 4-8. '' Saskatchewan Medical Quarteri) (hereafter SMQ ), Vol. 9, No. 3 (December, 1949, p. 25. " "New plans for health services," Leader Post, 22 May 1947. 26 SMQ,Vol. 9, No. 1 (May, 1945), p. 15. " SABR, McLeod Papers, fde 1, "Minutes of Meeting of the Advisoiy Committee, March 2 & 3,1945," p. 7. " SMNSCPS, £ïle "Negotiations: Douglas," Dr. John A. Valens to T. C. Douglas, 7 March 1945; Douglas to Dr. Valens, 8 March 1945. '' SMNSCPS, fùe 6- 14-0 ("Municipal Medicine"), 12 Mar& 1945. 'O Ibid. " SMQ, Vol. 9, No. l(May, 1945), p. 15. " Ibid., pp. 15- 16. " SMQ, Vol. 9, No. 3 (December, 1945), p. 27. 34 Ibid. "SMQ, Vol. 9, No. 1 (May, 1945), p. 21 36 Taylor, Health Insurance and Canadian Public Policy, op. cit., p. 248. " SMQ, Vol. 9, No. 1 (May, 1945), 17. Ibid. 39 ibid. 40 Ibid., p. 18. Ibid. 42 Ibid. 43 Ibid., pp. 19-20. * SMQ, Vol. 9, No. 3 (Decembcr, 1945), p. 27. 4s SMQ, Vol. 9, No. 1 (May, 1945), p. 20. 46 Ibid., p. 21. 47 SMQ, Vol. 9, No. 3 (December, 1945). p. 26. Ibid; SMQ,Vol. 9, No. 1 (May, 1945), p. 21. SMQ, Vol. 9, No. 3 pecernber, 1945), p. 28. 50 Ibid. SI SABR, Records of the Health Services Planning Commission (hereafter HSPC), file 12, "Mernorandun Re. Meeting of Health Services Planning Commission with Medical Conmittee: April 14, 1945," p. 2. "Ibid. 53 Ibid., p. 1. " Ibid. 55 SMQ, Vol. 8, No. 3 (September, 1944), p. 13. 56 Ibid., p. 14. 57 SMQ, Vol. 9, No. 3 (December, 1945), p. 28; SABR, Thomas Clement Douglas Papers (hereafter Douglas Papers), file 1 11 133 (14-24) Memorandwn for Douglas hmSheps, "Notes re Meeting with Health Insurance Cornmittee of Sask. College of Physicians & Surgeons," n. d (circa December 1945), pp. 2,4. sg Taylor, supra, p. 248. "SMQ? Vol. 9, No. 3 (December, 1945), p. 30. 60 SABR,Douglas Papers, füe 1 11,133 (14-24) "THE SUGGESTiON OF THE HEALTH INSURANCE COMMITI'EE OF THE COLLEGE OF PHYSICIANS AND SURGEONS IN THE MATTER OF THE ADMINSITRATIVE BODY FOR ANY HEALTH SERVICE PLAN iN SASKATCHEWAN,"23 August 1945, p. 3. 61 Premier Douglas' reservations regarding this demand concerned the SCPS' dual role as both licensingl regulatory agency of the medical profession on behalf of the public and the political amof organized medicine in Saskatchewan charged with safeguarding the profession's socio-economic interests. As Douglas observed in a reply to the SCPS memorandum on administration of August 23, 1945, under this anangement "differences of opinion" with respect to the policies of organized medicine, as opposed to professional qualifications alone, might affect a doctor's eligi'bility to practice medicine in a provincial medical care scheme. Douglas statcd that he would be hesitant to make this suggestion if physicians in the province had not "expressed their fear that their professional qualifications might not be the sole consideration if classification were detennined by a licensing body, which at one and the same time is the profession's bargainhg agent;" and were he not aware that the SCPS requested that applications and licenses to practise medicine in Saskatchewan "be accompanied by an undertaking that Uie applicant will not enter into municipal or other contracts without the approval of the College." This latter rcference to municipal contract practice may suggest that the provincial governent fcared that the inclusion of this clause might detcr fiturc initiatives to introduce non-traditional medical practice (eg. salaricd group pp practice) in a provincial medical service phSABR, Douglas Papers, file 111, 133 (14-24), reply to memorandum of August 23, 1945, p. 4. '' SMAfSCPS, file 2- 10- 1A ("Medical Advisory Committee"), "Meeting of the Negotiating Cornmittee of the Central Health Services Committee with Premier T. C. Douglas," 18 September 1945. 6' It is important to note that thm is no evidence in the SMQ and such correspondence and minutes that exist conceming these negotiations of any resistance by the HSPC and, more importantly, Premier Douglas to the inclusion of the aforementioned clauses that ifadhered to by the goverment would effectively preclude the establishment of a salaried medical service in Saskatchewan. indeed, these sources suggest that physician remuneration was not even an issue at the bargainhg sessions. SMA/SCPS, file 2- 10- lA(Medica1 Advisory Committee), "Meeting of the Negotiating Cornmittee of the Central Health Services Committee with Premier T. C. Douglas," 18 September 45. 64 Malcolm G. Taylor, "The Saskatchewan Hospital Services Plan: A Study in Cornpulsory Health insurance," (Unpublished Ph. D. Thesis, University of California, 1949), pp. 121-1 22. 65 It will be recalled in Chapter 2 that this clause was neither adhered to by municipal doctors, nor edorced by municipal councils. Until more doctors entered rural pradce, to restrict the municipal doctors to their contract arrangements would deny many residents access to a physician. As demostrated in Chapter 2, a sigGcant portion of the mlpopulation received medical care on a private ffs basis fiom salaried municipal doctors. Significantly, M. S. Anderson was not opposed to nich a restriction in principle, once al1 the residents of Saskatchewan had medical coverage. It would appear that it was these considerations, coupled with SCPS opposition, that saw the HSPC and the Committee's lay representatives assent to the removal of this clause. SWSCPS, file 748(Advisory Committee Health Services Planning Commission), "Minutes of the Meeting of the Advisory SubCommittee on Local Health Services Held April22, 1945," p. 1. 66 Ibid., p. 5. 67 SMAISCPS, file "Dr. Houston's Municipal Doctor Contract File," R K. Johnston & C. J. Houston to the College of Physicians and Surgeons, 12 September 1945. 68 SMQ, Vol. 9, No. 3 (December, 19451, p. 12. 69 Ibid. 70 SABR,Douglas Papers, 11 1, 133(14-24), Mindel C. Sheps to al1 physicians in Saskatchewan, 27 June 1945. 71 SMNSCPS, file 7-4-8 (Advisory Committee Health Services Planning Commission), "Minutes of the Meeting of the Advisory Subcommittee on Local Health Services Held April22, 1945," p. 7. 72 Ibià. 73 SABR, McLeod Papers, file 27, "Memo Re. Rural Municipality of Lajord. No. 128 Health Services Scheme," 7 May 1945. 74 Ibid., p. 5. " Since 194 1 legislation permitted malmunicipalities to enter agreements with MSI for the provision of medical services on a fee-for-service basis with the approval of the Minister of Health. In 1946 the govemment consolidatcd al1 the statutory provisions authoriziag municipal medical care plans under a section of the Health Services Act. This act set forth the meam by which a municipaiity couid provide medical care services to its residents. The provisions of the Act pcmiitted contracts with mutual medical societies but no other body. As nich, the authority for a municipality to enter into contracts with MSI was elininated. SABR, Records of the Department of Hedth, Policy Research and Management Services Branch, file 8, "Summary of Material on Medical Care Program for Saskatchewan" no date (circa 1959-61) p. 25. 76 SABR, HSPC, file 12, C. J. Houston to Dr. Mindel Sheps, 10 May 1946. * Ibid. " Ibid., Dr. Mindel Sheps to C. J. Houston, 14 May 1946. 79 ibid., C. F. W. Hammes, Deputy Minister of Health to C. J. Houston, 15 May 1945. 80 Order in CounciI867145. Regina, Tuesday 12,1945. Saskatchewan Gazette, 30 June 1945. 8 I T. C. Douglas, "The Doctor in Saskatchewan's Health Plans," WQ,Vol. 9, No. 1 (May, 1945), p. 28. 82 For example, a SCPS Bulletin issued in March of 1943 noted that: "We al1 kmw that, individualiy, the Doctor is everyone's friend, but as a group we are ngarded as anything but that." Quoted in Taylor, Health Insurance and Canadian Public Policy, supra, p. 242. 83 SABR, HSPC, file 12, ''Mernorandun Re. Meeting of Health Services Planning Commission with Medical Committee: April 14, 1945," p. 2. 84 Order in Council867145. Regina, Tuesday, June 12, 1945, Regdations Respects Grants and Loans with Respect to Medical Services under the Health Se~cesAct. Saskatchewan Garzette, 30 June 1945. 85 SABR, HSPC, file 12, C. J. Houston to Dr. Mindel Sheps, 10 May 1946; Mindel C. Sheps to C. J. Houston, 14 May 1945. 86 Ibid., p. 2. 87 See for example Dr. L. Brown's review of the Central Health insurance Cornmittee's work and negotiations with the Douglas government at the SCPS annual meeting of September 20-2 1, 1945. SMQ, Vol. 9, No. 3 (December, 1945), p. 11. 88 SWSCPS, file 6-14-3, C. J. Houston to Dr. J. G. K. Lindsay, 26 September 1945. " SMQ,Vol. 9, No. 2 (September, 1945), p. 15. 90 SMAISCPS, füe "Dr. Houston's Municipal Doctor Contract File," R K. Johnson & C. J. Houston's report to Central Health Insurance Committee on municipal doctor contracts, 15 September 1945. 91 SMAISCPS, file 6-13-0, C. J. Houston to Dr. J. G. K. Lindsay, 26 September 1945. 92 SWSCPS, file 6- 13-0, C. J. Houston to Lindsay, 7 Febnrary 1946. " SCPS/SMA, file "Dr. Houston's Municipal Contract file," "Minutes of Meeting of Central Health Services Cornmittee," 2 1 October 1945, p. 5. 94 SMAfSCPS, file 2-10-l(Medica1 Advisory Committee), "Meeting of the Negotiatuig Committee of the Central Health Services Committee with Premier TIC. Douglas," 3 November 1945, p. 2; SABR, Douglas Papers, file 11 1 133(14-24) Lindsay to Douglas, 20 Novcmber 1945; Lindsay to Douglas, 25 October 1945. 95 QI December 30,1945, the SCPS requested the removal of "Mindel and Cecil Sheps fiom the formation or implementation of health services in the province" - a demand Douglas flatly rejected. However, Douglas told the SCPS that Mindel had found it necessary to resign as secretary fiom the HSPC for family reasons. She was temporarily replaced by hahusband Dr. C.G. Sheps, who became acting chairman of the HSPC (a position that had been unofficiaUy held by Mindel) and Dr. O. K. Hjertas who became secretary. The Drs. Sheps would leave the province during the summer of 1946. Under Cecil Sheps' replacement, Dr. Frederick D. Mott, a former senior offtcer in the United States Public Health Service and a graduate of the McGill Medical School, relations between the provincial govenunent and the SCPS would improve considerably. 96 Once an area was declared a health region, a regional health board would be set up comprised of representatives fkom the municipalities of the region, The health boards would be empowered to plan, provide, finance, as well as administer health care services in the region, with the advice of various technical committees composed of doctors, nurses etc; subject to the approval of the Department of Health through arrangements with local hospitals, physicians etc. Regdations Goveming the Establishment of Health Regions Under nie Health Services Act. Chapter 5 1 of the Statutes of Saskatchewan, 1944. (Second Section); SABS, Houston Papers, fde 41, Health Services Planning Commission, "Pertinent Facts About Health Regions," n.d., p. 1; SMA/SCPS, file 6-13-6 meaith Region #6, Moose Jaw), material on regional organkation aud health services forwarded to municipal councits in the proposed health region #6,Moose Jaw, 25 May 1945, p. 5. 97 Harry Dickinson, "The Struggle for Sîate Health Insurance: Reconsidering the Role of Saskatchewan Farmers," Studies in Political Economy, Vol. 4l(Summer 1943), p. 148. 98 For an account of the establishment of the Swift Current Health Region see Feather, "Fonnation of the Swift Current Health Region," op. cit. 99 Several accounts of the formation of îhe Swift CmntHealth Region indicate that at lest four nual municipalities provided their residents with general medical care. A document prepared in the early 1960- 1961 on municipal medicai care plans in Saskatchewan States that sevcn rural municipalities, and several towns and villages discontinued their municipal medical care plans when they joined the Swift Current Medical Care plan. Feather, supra, p. 70; SMQ,(April, 1947) p. 21; SMA/SCPS, Advisory Planning Conmittee on Medical Care, "Mcmorandwn on Municipal Medical Care Plans in Saskatchewan," circa 1960-1961, p. 1( note 1.). 'Oo The Rural Municipalities of Riverside No 168, Webb No. 138, Pittviiie No. 169 and, possibly, Carhi 229 had fee-for-service plans. SCPS/SMA, ("Dr. Houston's Municipal Contract FiIe"), Mindel C. Sheps to Dr. C. J. Houston, 7 May 1945; Feather, supra, p. 71; SMQ,Vol. 10, No. 2 (July, 1946), p. 8. Io' SABR, McLeod Papers, füe 38, "Fee For Service Schnws," circa 1944 -1945. 'O2 Car1 Kjorven was reeve of the RM of Riverside No. 168. Stewart Robinson was the former secremy - îreasurer of the RM of Webb, 138. Feather, supra, p. 71. 1O3 It is worth noting here that Burak was an outspoken advocate and promoter of a fee-for-service medical care plan fmt established in his RM of Pittville in 1937. The "Pithdle Plan" scrvcd as the mode1 for many of the province's fis plans, including those in the Swift Current area. From the beginning of his one man crusade to establish a health region in the Swift Currcnt area, Burak maintained that a complete rnedical service codd be provide by the region for $9- 10 pcr ptrson, bascd on the operational experience of the Pihlle fee-for-service medical care plan. SABR, McLeod Papers, file 19, "Health Plans: An address delivered to the Convention of Saskatchewan Hospital Association, At Moose Jaw, Sask., October 3 lst, 1944 by W. J. Burak, Hazlet, Sask," p. 2; Feather, supra, pp. 7 1-72. '04 SMQ, Vol. 10, No. 2 (July, 1946). p. 8. los Ibid. 1 O6 At the second executive meeting of the Swift Cunent Health Board Febniary 14, 1946, it was moved, without any apparent objections, that the Secretary write to the health region's medical advisory comrnittee asking for kirca-operation in the establishment of a ffs medicai care scheme and that a tentative offer of 50% to 65% of the SCPS fce-schedule be made. SABSoRecords of the SwiA Current Health Board And Cornmittee Minutes (hereafter SCHB), file 11, Minutes of Regional Board Meeting, 17 January 1945; 14 Febniary 1946. 107 SABR, HSPC, file XII, Memo hmDr. O. K-Hjertas to Dr. Sheps Re. Meeting held in Swift Cunent of the Regional Executive and the medical men of the District, 6 May 1946. 1 O8 Lipset, for example, States that it was the Douglas govenuncnt (as opposed the SwiA Current Health Board) that "agreed to pay the physicians[in Swift Current] on a fee-for-service basis.. .." Lipset, supra, p. 293; See also Jacalyn Dufiand Leslie A. Falk, "Sigerist in Saskatchewan," op. cit., p. 676. 109 The scheme was financed by a combined property and personal tax and a gant fiom the provincial govenrment. This state subsidy, approximately 10% of the health regions medical seMces budget, was comprised of the 25 cents per capita and equalization grants the various municipalities that constituted the health region were entitled for purpose of fiaancing municipal medical care plans. Records of the Department of Heaith, Policy Research and Management Services Branch, file 14(a)"History of Public Health in Saskatchewan (with a special refemce to the History of the Swift cment Health Region)," circa l958., p. 8; "History of the SwiA Curent Health Region Medical Cam Plan: 1946- 1966, June, 1969," p. 11 ; SMQ, Vol. 10, No. 2 (July ,l946), p. 8; Taylor, Health Insurance and Canadian Public Policy, supra, p. 251. 110 SABR,McLeod Papers, file 37, "Report on Dr. Hjertas' Trip to Moose Jaw with the Premier on Jan 7, 1946." "' "Ask Voice On Board," Saskatoon Star Phoenix, 30 April 1946. 113 "Medical Cwpwidens scope," Leader Post, 1 May 1945. 1 Id "Medical Co-op Directors Authorized to Bonow Million for Development," Saskatoon Star Phoenix, 30 April 1946. t 15 "Medical Centres Planned At Various Rural Points," Saskatoon Stur PhoenLx, 30 April 1946. "Trial Period for Srate Medicine," Saskatoon Stur Phoenix, 8 May 1946 117 "Medical Co-op Directors Authorized to Borrow Million for DeveIopment," Saskatoon Star Phoenix, 30 April1946. Il8 SWSCPS, file "Ministcr of Public Health: Douglas; Negotiations," Dr. J.G.K. Lindsay to T. C. Douglas, 25 June 1946. Il9 SWSCPS, file "Ministcr of Pubtic Health: Douglas; Negotiations," T. C. Douglas to Dr. J.G.K. Lindsay, 25 Sune 1946. 120 Taylor, Heaith Insurance and Canadian hblic Poiicy, supra, p. 260. 12' SABR, HSPC, fde 121 b, E.J. Loer to Dr. F. D. Mot& 12 Octok 1946. 122 lbid; The medical codperative subsequently petitioned the provincial govemment to establish a "tirst rate clinic" in connection with the University Hospital and Medical Schoal and that it be made "fully availablc" to ali its membcrs and the public at large. SABR, HSPC, file 121b, E.J. Loer to Dr. F. D. Mott, 7 November 1946. l2 SABR, HSPC, file 121b, E.J. Loer to Dr. F. D. Mott, 12 October 1946. 12' A survey of the municipal doctor system undertaken by the HSPC in 1947 revealed that there were only 12- 13 ffs schemes, indicating that the vast majority of municipalities pre ferred salary as opposed to ffs contacts. SMAISCPS, Health Service Planning Commission, Research and Statistics Division, 1948, "Survey of Municipal Doctor Plans Operating in 1947." 12s "Another Deficit," Saskatoon Star Phoenk, 20 October 1947. 12' SMQ,Vol. 2.. No. 4 (December, 1947), p. 44. 12' lbid. 128 SABR, HSPC, file 143, F. D. Mott, "Memorandum For File: HSPC 6-2-2: re. Meeting with Executive of S.A.R.M.," 25 October 1947. 12' The SCPS agreed to accept payment at 85% the 1947 fee schedule for 1948, which SARM considered a signrficant gain. SABR, HSPC, file 143, C. G. Brydan, Secretary of SARM to Dr. F. D. Mot& 23 March 1948. 130 SABR, HSPC, file 143, F. D. Mott, Memo For File: HSPC 6-2-2: re. meeting with Executive of Saskatchewan Association of Rural Municipalities, 15 January 1948; F. D. Mott to T. C. Douglas, "Address at Convention of Saskatchewan Association of Rural Municipalities," 25 Febmary 1948. 131 in 1955 proposais for the establishment of regional fee-for-service medical service plans based on the Swift Current mode1 in the Rural Regina and Assini'boia-Gravelbourg health regions were defeated in two plebiscites. In an analysis of the voting paterns, Milton R 1. Raemer concluded that people enjoying the benefits of low-cost salaried municipal doctor schemes were inclined to oppose the fee-for-service regional plans, fearing loss of autonomy, and higher costs as a result of fee-for-service remuneration. Joan Feather, "hpact of the Swift Current Health Region: Experiment or Model?" Prairie Forum,Vol. 16, No. 2 (Fall, 199l), p. 230. "'SABR, HSPC, file 130, P. D. Mott, "Memorandum for îhe File: re. meeting of December 10, 1947 with S.A.R.M. Regina Health Services Union etc. conceniing 1947 Contract Schedule of Fees and Related Problems," n.d. 133 E. A. Tollefson, Bitter Medicine: ï%eSaskatchewan Medicare Feud, (Saskatoon, Saskatchewan: Modern Press, l963), p. 4 1. 134 SMABCPS, file 7-4-8, "Advisory Cornmittee to the Health Services Planning Commission, Minutes and Proceedings, May 9 and 10, 1947," p. 33. 136 Ibid. "'"New plans for health services," Leader Post, 22 May 47. "'SABR, Records of the State Hospital and Medical League, füe 8, "My Mernories of the State Hospital and Medical League by Joseph A. Thain," p. 6. 139 Mainîaining that the ffs method was "the antithesis of prevcntive medicine," and the Swift Currcnt Health Region's ffs medicai case plan was "'uusatisfactory"' as it is impossible to budget satisfactorily in advance and that it has proven to be too costly," the Saskatoon CCF constituency at its annuai convention June 13, 1947, resolved: "l'bat in the establishment of future Health Regions, the Government bring strong pressure to bear to ensure adoption of a salary basis of payment of medical practitioners so that that the p~cipleof 'paying the doctors well to keep the people well' may have an opportunity to be realized." This nsolution was in turn submitted to the Resolution's cornmittee, chaireci by Premier Douglas, at the Provincial CCF Convention July 29,30,3 1, 1947, in Saskatoon. The following resolution was passed: 'We urge that whercver possible the Provincial Govenunent and the Regional Health Board should encourage the hiring of doctors on a salary basis." SABS, CCF Papers, file 11 55(1), "Resolutions passed at the Saskatoon Constituency Convention on June 13, 1947," pp. 5 176 - 5 177; fde 1 11, Minute Book, 1944 - 1948(#4) "Niautes of Twellth Annual Provincial CCF Convention July 29,30,3 1, 1947 - Bessborough Hotel Saskatoon - Sasic," # 1053. 140 SABS, Pamphlet Collection, "Editorial: Well ûrdered Medical Services," Health Services Review, (October 1947), p. 4. 141 SABS, Pamphlet Collection, "Brief To The Govenunent of The Province of Saskatchewan: Submitted by The State Hospital and Medical League 1946," Health SeMces Review, Vol. 2., No. 1 ('May 1946), pp. 6-7; "Brief To The Government of The Province of Saskatchewan: Submitted by The State Hospital and Medical League February 8, 1947," Health Services Review, Vol. 3., No. l(Apri1, 1947), pp. 6-7. 14' SABS, Pamphlet Collection, "editorial: Well Ordered Medical Services," Health Services Review (October 1947). p. 4. 143 Ibid. 14' "Physicians Shy From Sask. Posts," Saskatoon Star Phoenix, 21 February 1947. SABR, HSPC, fde Ze, "Memorandum For The File: re. Employment of Speciaiists by Health Region No. 1.- 30 November 1948." 146 SABS, Pamphlet file, "League Officiais Address Sask. Assn. Of Rural Municipalities," Health Services Review, Vol. 3.' No. 5 (Aprii, 1948), p. 19. 147 SABR,HSPC, file 105c (lof 2), T.C. Douglas to Dr. G. Ferguson, 26 Febnrary 1949. 14' Ibid. SABS, MacLean Papers, file 29, Dr. Fred Mott to Dr Hugh MacLean, 21 March 1949. 150 SMAISCPS, file "Dr. Houston's Municipal Contract file," C. J. Houston to Dr. G. Gordon Ferguson, n. d., circa late 1940s. SMAISCPS, Advisory Planning Committee on Medical Care, "Memorandum on Municipal Medical Care Plans in Saskatchewan," circa 1960-1 961, p. 2. 1st SMNSCPS, Advisory Planning Cornmittee on Medical Care, "Memorandum on Municipal Medical Care Plans in Saskatchewan," circa 1960-1961, p. 2. 152 SMAISCPS, file 748, "Advisory Committce to the Health Services Planning Commission, Minutes and Proceedings, May 9 and 10, 1947," p. 33. ppppp 153 In 1950 there wcre 173 plans providing coverage to 20,000 penons, approximatcly 24% of the province's 833,000 residents; National Archives of Canada, Papen of Frederick D. Mot, Milton 1. Roemer, "Prcpaid Mcdical Care and Changing Needs in Saskatchewan,'Paper prcsented at the Amcrican PubIic Health Association, Kansas City, Missouri, November 14, 1955; p. 4. lS4 McLeod and McLeod, Tornrny Douglas, op. cit., p. 150. 155 Naylor, Pnvate Practice, Public Payment, op. cit., p. 178. Chapter 6 CONCLUSION An examination of Saskatchewan CCF party health policy reveals that the CCF was never committed to, or an advocate of, the establishment of a state salaried medical service. After the CCF came to power in Saskatchewan Premier Douglas repeatedly denied that his government would place the medical profession on salary. Douglas' health policy statements in the Autum of 1944, coupled with his immediate consent in August of 1944 to ffs payment for a medical services plan for old age pensioners and other social assistance beneficiaries, suggest that his governmentfs objective was to provide medical care to the citizens of Saskatchewan as rapidly and amicably as possible with the CO-operation of the medical profession. Thus it would seem that Premier Douglas and the Saskatchewan CCF had rejected a state salaried medical service long before the HSPC presented such a proposa1 to its advisory committee on March 2, 1945. Indeed, Premier Douglas immediately rejected the HSPC recornrnendations for a salaried service when the SCPS expressed its opposition to them on March 21, 1945. In this context there is no documentary evidence to suggest that after Douglas1 meeting with the SCPS on March 21, 1945, the Premier and the Cabinet "weighed the situation and assessed the opposition of the ~ollege,"' and then rejected the HSPC recommendations for a salaried medical senrice as Malcolm G. Taylor maintains. Nor does it appear that the CCF government considered implementing the 1945 HSPC physician remuneration recomrnendations in the face of SCPS opposition after oug glas' meeting with the SCPS as existing scholarship suggests.' After March 21, 1945, the various departures from the 1945 HSPC proposals for a salaried medical service in rural Saskatchewan occurred without any apparent resistance from the Douglas government or the HSPC. Accordingly, a careful examination of the events, negotiations, and documentation concerning the development of medical services in Saskatchewan during the CCF's first term in office reveals that there was no confrontation between the Douglas government and the SCPS with regards to salary remuneration - apart from the fact that the HSPC devised and presented to its advisory committee proposals for a salaried general practitioner service in rural Saskatchewan. It would appear that Taylor both overstated and over-emphasized the importance and intensity of the friction concerning the 1945 HSPC proposals in his account of the development of Saskatchewan medicare; a fact that Dr. C. 3. Houston of the SCPS, who was present and a key participant at the negotiations in the formative 1944 - 1946 period, took great exception with in reviewing a draft of Taylor's Health Insurance and Canadian Public Policy. With respect to the 1945 HSPC proposals and their architect Mindel Sheps, Houston writes emphatically: Certainly it [in Houston's words "the so-called Sheps report of 1945"] was not pursued by tbe Department nor ever &carne any sembiance of public policy re. govenuaent policy. And now 1 see it is resurrected fiom the Dead! - and presented as a source of Rift and Confiontation(sic)! Actually I had thought po ont even in govemmcnt had ever taken Mindel seriously - so 1 was most surprised to see her littie fihg given any prominence in the influence of event~.~ These aforementioned inaccuracies in the established historical accounts of the developrnent of Saskatchewan medicare must be taken into account in determining why the CCP did not establish a salaried medical service in rural Saskatchewan as recommended by the HSPC in 1945. Historians offer three interpretations about why the CCF government of Tomrny Douglas rejected the 1945 HSPC proposals for the establishment of a salaried general practitioner service in rural Saskatchewan. First, Taylor States that the HSPC proposals were not implemented because of SCPS opposition and its threat that such a plan would both induce many physicians to leave the province and deter others from settling in Saskatchewan. Second, David C. Naylor maintains that Premier Douglas' "concern was to impiement programs of health services as amicably and rapidly as p~ssible."~Naylor suggests that this fact, coupled with SCPS opposition and the threat that the HSPC plan would both cause doctors to leave and discourage immigration, exacerbating the province's existing doctor shortage, led to Premier Douglas' concessions to the medical profession in 1945-1946. Third, Lipset intimates that the compromises to the original HSPC proposals occurred because the CCF was not backed by a public that supported the establishment of a salaried medical service. Lipset argued that the Douglas government did not follow the 1945 HSPC recommendations because a) the electorate did not understand or demand qualitative changes in medical care, and b) there was a lack of organized pressure groups that supported qualitative changes. The Douglas government faced a medical profession united in its opposition to the development of the municipal doctor system into a state salaried medical service. The SCPS submission ta the 1943-1944 Special Select Committee on Social Security and Health Services included the 1934 CMA principle on health insurance that "contract salary service be limited to areas with a population insufficient to maintain a general practitioner in the area, without additional support form the Insurance F~nd.~' This clause was inserted directly after the following the statement highlighted by Malcolm G. Taylor: "We think that the scheme can be combined with something equivalent to the Municipal Doctor Plan, with payment on a combined salary and fee basis .f'6 In this context, the SCPS clearly was not stating that it was agreeable to the establishment of a substantial, let alone a province- wide, salaried general practitioner service in rural Saskatchewan with ffs payment for major surgery as Taylor intimates. Rather, the SCPS was indicating its acceptance of combined salary/ffs payment in areas where ffs alone was not feasible. It is unlikely that Premier Douglas and the HSPC were "unprepared" for the SCPS negative response to the 1945 HSPC proposals, as Taylor maintains.' It is difficult to conceive that the CCF was unaware of the SCPSO ardent opposition to salary remuneration. Although the municipal doctors were more accepting of salary remuneration both in and outside the context of a provincial medical service scheme than their colleagues in private practice, they were equally opposed to straight salary remuneration for the provision of general medical services. The municipal doctors attached great importance to their lucrative private practice privileges and their substantial private income, which they referred to as "outside practice." This private practice did not consist exclusively of ffs payment for major surgery, as Taylor and other scholars intimate, but primarily of general medical services to private patients both within(towns and villages) and outside the boundaries of the contracting municipality. Hence when R. K. Johnston informed Premier Douglas on March 21, 1945, that the municipal doctors wanted a practice "consisting of municipal contract work and outside practice and that on the whole they favoured the municipal work as it was now operated,"' he was not stating that the municipal doctors were in favour of straight salary remuneration with the exception of major surgery on a fis basis as Taylor infers. Rather, he was protesting the HSPC straight salary munjcipal doctor contract. Dr. C. Stuart Houston's asaessment that the HSPC proposals "at once alienated the salaried municipal doctors, for it would deny them any right to private practice or to attend any one from beyond a right area b~undary,"~isa more accurate interpretation of the municipal doctorsf response to the HSPC proposals. R. K. Johnston clearly was not, to quote Taylor, a "dissenthg voice" in the College delegation on March 21, 1945.1° Although the CCF does not appear to have considered implementing the 1945 HSPC programme for a salaried medical service in the face of this fervent opposition as existing scholarship maintains, one may suggest that the Douglas government would have followed the HSPC physician remuneration recornmendations if the medical profession had not been opposed. On the basis of this probability alone, SCPS opposition clearly was a factor in the rejection of the 1945 HSPC proposals . Premier Douglas* declaration to the SCPS negotiating comrnittee on March 21, 1945, that the government was not committed to salaried state medicine and the forthcoming departures from the HSPC proposals for a salaried medical service were not a capitulation to the demands of the medical profession as such. Rather, they were a reiteration and confirmation of a policy decision first enunciated publicly in the Autumn of 1944 that the government was not going to force the medical profession into a salaried medical service. One may suggest, however, that the SCPS' fervent opposition to salaried employment contributed to this earlier decision that led to the Premier Douglas' immediate rejection of the HSPC proposals on March 21, 1945. Although SCPS opposition was clearly a factor in the rejection of the HSPC proposals, the role of the province's doctor shortage and SCPS threats that the development of a salaried medical service would compel doctors to leave the province and deter others from corning in this decision is less discernible. The Douglas government appears to have rejected the concept of a state salaried medical service such as that envisaged by the HSPC long before the SCPS made such threats to Douglas on March 21, 1945. If the CCF had contemplated implementing a salaried medical senrice, it would have had to consider that such an initiative would probably cause doctors to leave the province and discourage immigration, thereby exacerbating the province's existing doctor shortage. The vast majority of the highly mobile medical profession in Saskatchewan and Canada was opposed to salary remuneration or preferred ffs. And the province was surrounded by jurisdictions with ffs payment . Nonetheless, the establishment of a state salaried medical service was seen as a viable policy option in Saskatchewan as evidenced by the large number of lay organizations both interested in and engaged in the provision of health services that advocated such a scheme for the province; the recommendations and proposals for the developrnent of a salaried service by the CCF health plamers; and the endorsement of the 1945 HSPC proposals on March 2, 1945, by its advisory cornmittee. In the accounts of the various meetings and forums where support for the establishment of a state salaried medical service was expressed, such as Premier Douglasf meeting with the executive of SAM and the Swift Current Regional Health Board (SCHB) in 1947, there is no record of government officials or lay persons stating that a salaried service was not feasible. The numerous organizations that advocated or supported the establishment of salaried medical service, such as the SHML, the SARM executive, etc., were fully cognizant of the aforementioned disadvantages and difficulties of implementing such a service. The HSPC and the supporters of salaried rnedicine appear to have believed that the prospect of assured and generous remuneration, pensions, as well as modern and well-equipped facilities would attract a sufficient number of physicians for the developrnent of a salaried medical service. The establishment of a salaried medical service in Saskatchewan without the CO-operation of the medical profession (and even outright SCPS opposition and obstruction) and with the province's doctor shortage was viewed as a viable course for the province by the HSPC and a large number of organizations representative of Saskatchewan society. In this context, one may suggest that the 1945 HSPC proposals were not rejected by the CCF solely on the basis of SCPS opposition and the threat of loss of doctors. Other factors must have been involved. Although the establishment of a salaried medical service was considered to be ieasible in Saskatchewan, because of SCPS opposition and the probable loss and deterred immigration of doctors, the provision of accessible medical services to al1 the people, as promised by the CCF, would take longer to realize. Perhaps this was unacceptable to Premier Douglas. As Douglas told the SCPS on March 21, 1945, his "concern was to provide medical care to everyone as rapidly as possible. This stated objective would be attained far more quickly with the CO-operation of the medical profession and the development of medical care services on a ffs basis. Hence Douglasf statements to the SCPS in the autumn of 1944 that medical services would be provided "on whatever basis the government could get possible CO-operation with the medical profe~sion.~" DouglasJ statements to the SCPS and the general public, beginning in the autumn of 1944, and his negotiations with the College for the provision of rnedical services to pensioners and other social assistance beneficiaries, support Naylorfs interpretation that the HSPC recommendations for the establishment of a salaried medical service were not implemented because Premier Douglas4 'concern was to implement programs of health services as amicably and rapidly as possible (Douglas' very words to the SCPS on March 21, 1945) ."" Public support for the HSPC proposals and a state salaried medical service was not lacking as Lipset contends. Indeed, T. C. Douglas appears to have rejected this policy option for Saskatchewan in 1944 and in tum the 1945 HSPC proposals within an environment of considerable support for such an initiative. There was a broadly- based, well-organized and determined popular movement for the establishment of state salaried medical service in the 1940s led by the State Hospital and Medical League. So strong was this movement that the SCPS launched a comprehensive and sophisticated public relations campaign in 1943 to counter this perceived threat to its interests. The solid, province-wide support for a salaried medical service was revealed in the subrnissions to the Health Services Survey Commission(HSSC) chaired by H. E. Sigerist, the last and most consultative(in terms of representati0ns)of three government inquiries into health services in Saskatchewan in 1943-1944. In addition to the SHML, the two agriculture organizations that appeared before the commission, and a diverse number of trade unions, rural municipalities, and citizen organizations indicated their support for salaried state medicine to the HSSC. Additional support for the establishment of a salaried medical service in Saskatchewan resided with the three medical service co- operatives in Regina, Saskatoon, and Melfort. In their briefs to the HSSC the CO-operatives endoreed contributory health insurance with doctors paid by salary or capitation. Like the SHML, the medical co- operatives claimed that the fis method was not conducive to preventive medicine, and vocally so, to the extent that the SCPS was compelled to address these assertions in its brief to the Sigerist ~ommission. ~his segment of the movement for a salaried medical service in Saskatchewan clearly desired what Lipset considers "qualitative changes in medical care. SMdoes not appear to have officially endorsed the establishment of a state salaried medical service as Naylor suggests. Throughout the 1940's this organization indicated that it was agreeable to ffs payment. However, according to HSPC Commissioner F- D. Mott's observations at a 1947 meeting, there was strong support for salaried state medicine among many members of the SARM executive. Thus, contrary to Lipsetts assertion, there appears to have been a considerable number of organized pressure groups that supported the establishment of a state salaried medical service. One may suggest that these organizations would have, in Lipset's words, acted to "counterbalance" the SCPS if the CCF had followed the 1945 HSPC recornmendations for the establishment of a salaried general practitioner service in rural Saskatchewan.ls Some of these groups and their representatives, in a variety forums, publicly criticized ffs payrnent in the Swift Current Health Region and lobbied the provincial government to both place doctors on salary and encourage the development of salaried medical care schemes in the other health regions. The CCF clearly would not have been wanting for allies among the public if it had attempted to inaugurate a state-salaried medical service in the 1940's - either through an irnrnediate placement of al1 doctors on salary, or as the HSPC proposed, via an expansion of the province's existing salaried municipal doctor system. Indeed, the SHML and its broad and active membership was, as stated in its brief to the Sigerist Commission advocating salaried state medicine, "prepared to go to the limits side by side with any government having courage and conviction that these ideals can be attained."16 Several other factors made 1940,s Saskatchewan favourable to the implementation of the 1945 HSPC proposals. First, by the SCPS' own admission, organized medicine was not held in high esteem by the general public. Whether just or not, there was a perception in Saskatchewan that SCPS fee-schedules and payment demands were excessive. Second, there was a perception in Saskatchewan that the ffs method was too expensive and unsuitable for medical care plans because it did not allow for accurate budgeting. This belief was strengthened in 1947 as a result of actual and projected deficits of the Swift Current Health Region ifs medical care plan. As the SCPS observed in 1947, the rural municipalities were loath to accept ffs payments for municipal doctor plans for fear of being drawn into a ffs regional plan modelled after the Swift Current plan. In rural Saskatchewan, salary was the preferred method of physician remuneration for lay-controlled medical care plans, as evidenced by the fact that the vast majority of municipal doctor plans continued to operate on a salary basis. Thixd, the establishment of a state salaried medical service was not viewed as a radical policy in Saskatchewan, owing, in part, to the presence and popularity of the provincets extensive salaried municipal doctor system. As a result, in Taylor's woxds, 'the introduction of a system as radical as that proposed by the Commission [HSPC],wl' i.e. the expansion and development of the province's existing municipal doctor system into a salaried medical service, was not perceived to be radical by the people of Saskatchewan, let alone a departure from the development of health services in rural Saskatchewan since the 1930's. Indeed, the 1945 HSPC proposals seem to have been enthusiastically endorsed by its advisory committee representing a cross-section of the public. Public opinion clearly would not have been a great obstacle to the implementation of the 1945 HçPC recommendations for a salaried service. In this context, because the 1945 HSPC proposals were seen as a viable course for the development of a provincial medical services plan without the CO-operation of organized medicine, and many of the party's principal and active constituencies of support, such as the organized farming movement, labour, and the teaching profession favoured the introduction of a salaried medical service, one may suggest that if the CCF had been committed as a party, and more importantly as a government, to salary remuneration as some historians have claimed, the Douglas government would have implemented the 1945 HSPC recommendations for a salaried service in spite of SCPS opposition. In the final analysis, it would appear that the CCF government of T. C. Douglas did not follow the 1945 HSPC proposals for a state salaried medical service because; neither the party or government was committed to salary remuneration; the policy of the Douglas government was to provide medical services to the people of Saskatchewan as rapidly as possible with the CO-operation of organized medicine; and the medical profession, including the province's salaried municipal doctors, was fervently opposed to being placed on salary. Endnotes: ' Taylor, Health Insurance and Canadian Public Poiicy, op. cit., p. 248. ' It is worth noting hmthat Dr. Mindel C. Sheps was refhgto the Douglas governrnent's medicai care programme for old age pensioners and other social assistance beneficiaries, introduced in January of 1945, when she wrote to Henry Sigerist on March 8, 1945, that after "delay and temporizing, that [issue] was scttled just the way the doctors wanted it.. .in the direction we didn't want them to go." AIan Mason Chesney Medical Archives, Johns Hopkins Medical Institutions, Sigerist Papers, Box 25, Mindel Sheps to Henry E. Sigerist, 8 March 1945. She was not referrùig to the 1945 HSPC proposais for a salaried general practitioner service in rural Saskatchewan as Damand Faik suggest. Duffin and Falk, "Sigerist in Saskatchewan," op. cit., p. 676. 3 Saskatchewan Archives Board, Saskatoon, The Papers of Dr. C. J. Houston, file 23, Houston to Malcolm G. Taylor, 25 Febniary 1975, p. 8. ' Naylor, Private Pructice. Public Poyment, op. cit., p. 140. 5 SMNSCPS, The Council of the College of Physicians and Surgeons of Saskatchewan, "Submissions To The Select Committee of the Legislative Assembly of Saskatchewan, March 1943," p. 5. Ibid., p. 4. ' Taylor, supra, p. 245. Ibid., p. 246. C. Stuart Houston, "The early years of the Saskatchewan Medical Qmerly," op. cit., pp. 1127-1 128. 10 Taylor, supra, p. 246. Saskatchewan Medical Quurteriy. Vol. 9, No. 1 (May, 19451, p. 17. '' "Adequate Health Service For Al1 The People is C.C.F. Ah," Wertem Pioducer, 28 September 1944. t 3 Naylor, supra, p. 140. 14 Lipset, Agrarian Socialism, op. cit., p. 297. l5 Ibid. 16 Saskatchewan Archives Boud, Regha, Records of the Health Services Survey Cotumission, file 8, "Brief presented at Saskatoon to Doctor Sigerist and the perso~elof the HSSC fiom the State Hospital & Medical League of the Province of Saskatchewan," p. 15. 17 Taylor, supra, p. 248. BIBLIOGRAPHY ABBREVIATIONS AMCMA Alan Mason Chesney Medical Archives, Johns Hopkins Medical Institutions NAC National Archives of Canada SABR Saskatchewan Archives Board, Regina SABS Saskatchewan Archives Board, Saskatoon SMA/SCPS Archives of the Saskatchewan Medical Association and the College of Physicians and Surgeons of Saskatchewan URLSC University of Regina Library, Special Collections PRIMARY SOURCES Governent Documents: Unpublished Saskatchewan. Records of the Department of Health, Policy Research and Management Services Branch. 1945-1949. (SABR) . Saskatchewan. Records of the Health Services Board. 1934-1944. (SABS). Saskatchewan. Records of the Health Services Planning Commission. 1944-1949. (SABR). Saskatchewan. Records of the Health Services Survey Commission. 1944. (SABR). Saskatchewan. Records of the Legislative Assembly Office Unpublished Sessional Papers . 1943-1944. (SABR). Saskatchewan. Intersessional Comrnittee on Social Security and Health Services : Report to Select Special Committee on Social Security and Heal th Sentices Session 1944. (SABR). Saskatchewan. Health Services Planning Commission. Report on Regional Heal th Servi ces : A Proposed Plan. 1945 . Saskatchewan. Records of the Saskatchewan Reconstruction Council. 1944. (SABS). Governent Documents: Published Saskatchewan. Report of the Saskatchewan Reconstruction Council . Regina: King's Printer, 1944. Saskatchewan. First Report of the Select Special Cornmittee re Social Welfare, etc. Saskatchewan Legislative Journal. 1943. Saskatchewan. Select Special Committee on Social ~ecurityand Health Services: Final Report. Regina: King's Printer, 1944. Saskatchewan. Department of Public Health. History of the Swift Current Health Region Medical Care Plan, 1946-1966. Regina: The Department of Public Health, Research and Planning Branch, 1959. Saskatchewan. Health Services Planning Commission. Survey of Municipal Doctor Plans Operating in 1947. Health Services Planning Commission, Research and Statistics Division, 1948. Unpublished Documents Records of the State Hospital and Medical League. (SABR). State Hospital and Medical League, The Case For State Medicine. 1944. (URLSC). Records of the Co-operative Commonwealth Federation, Saskatchewan Section. 1937-1947. (SABS). Records of the Swift Current Health Board and Committee Minutes. 1946. (SABS). Political Pamphlets. (SABR). Pamphlet Collection. (SABS). Private Papers Papers of the Honourable Thomas Clement Douglas. (SABR). Papers of Dr. Chester J. Houston. (SABS). Papers of Dr. Hugh MacLean. (SABS), Papers of Thomas H. McLeod. (SABR). Papers of Dr. Frederick D. Mott. (NAC). Papers of Dr. Henry Sigerist. (AMCMA). Papers of the Honourable Dr. John Michael Uhrich. (SABR). Newspapers, Annuai Reports, Minutes, and Contemporary Joumals Annual Reports of the College of Physicians and Surgeons- 1930-1936. SMA/SCPS. Annual Reports of the Saskatchewan Medical Association. 1930-1936. SMA/SCPS. Minutes of the Annual Meetings of the College of Physicians and Surgeons of Saskatchewan, 1930-1936. SMA/SCPS. Minutes of the Annual Meetings of the Saskatchewan Medical Association. 1930-1936. SMA/SCPS. The Health Sentices Review (Regina). 1945-1948. (various issues) . Prince Albert Daily Herald. 1944-1945. (various issues) . - Regina Daily Star. 1937. (various issues) . Leader Post (Regina). 1934-1947. (various issues) . Saska tchewan Medi cal Quart erl y. 1937-1947. (various issues). Saskatoon Star Phoenix. 1944 -1947. (various issues) . Western Producer (Regina). 1936-1944. (various issues) . Published Diaries, Memoirs and Contemporary Accounts Coppock, Frank H., "The Menace of Contract Practice," Canadian Doctor, (March, l938), pp. 27-28. Johnston, R. K. , "We Like Municipal Contract Practice ! " Canadian Doctor, (May, 19381, pp. 17-19. Roemer, Milton I., "Prepaid Medical Care and Changing Needs in Saskatchewan,'' Paper presented at the American Public Health Association, Kansas City, Missouri, Novernber 14, 1955. Rorem, Clarence Rufus. The Municipal Doctor System in Rural Saskatchewan. Chicago: University of Chicago Press, 1931. Sigerist, Henry E. "Medical Care for Al1 the People," Canadian Journal of Public Health, Vol. 35, No. 7 (July, 19441, pp. 253-267. Sigerist, Henry E. Autobiographical Writings. Selected and Translated by Nora Sigerist Beeson. Montreal-Kingston: McGill-Queens University Press, 1966. Sigerist, Henry E. Medicine and Heal th in the Soviet Union. Citadel Press. 1947. SECONDARY SOURCES ARTICLES Dickinson, Harley D., "The Struggle for State Health Insurance: ~econsiderin~the ~ole-ofSaskatchewan FannersfW Studies In Political Economy, 41, (Sumrner, 1943), pp. 133-156. Duf f in, Jacalyn and Falk, Leslie A, "Sigerist in Saskatchewan: The Quest for Balance in Social and Technical Medicine," Bulletin of the History of Medicine, 70, (1996), pp. 656-683. Duf f in, Jacalyn, "The Guru and the Godfather: Henry Sigerist, Hugh MacLean and the Politics of Health Care Reform in 1940s Canada," Canadian Bulletin of Medical History, Vol. 9, (1992), pp. 191-218. Feather, Joan and Mathews, Vincent L, "Early Medical Care in Saskatchewan," Saskatchewan History, Vol. XXXVII, No. 2 (Spring, 19841, pp. 41-54. Feather, Joan, "Prorn Concept to Reality: Formation of the Swift Current Health Region, " Prairie Forum, Vol. 16, No. 1 (Spring, 1991) , pp. 59-60. Feather, Joan, "Impact of the Swift Current Health Region: Experiment or Model?," Prairie Forum, Vol. 16, No. 2, (Fall, 1991), pp. 225-248. Fierlbeck, Katherine, "Canadian Health Care Reform and the Politics of Decentralization," in Christa Altenstetter and James Warner Bjorkman ed. Heal th Policy Reform, National Variations and Globalization (London: Macmillan Press Ltd, 1997), pp. 17-38. Houston, C. Stuart, "The early years of the Saskatchewan Medical Quarterly," Canadian Medical Association Journal, Vol. 118 (May, 1978) , pp. 1122-1128. Houston, C. Stuart, "Saskatchewan's municipal doctors: a forerunner of the medicare system that developed 50 years later," Canadian Medical Association Journal, Vol. 151, No. 11 (December, 19941, pp. 1642-1644. Mombourquette, Duane, "An Inalienable Right: The CCF and Rapid Health Care Reform, 1944-1946," Saskatchewan History, Vol. 43, NO. 3 (1991), pp. 101-116. Ostry, Aleck, "Prelude to Medicare: Institutional Change And Continuity in Saskatchewan, 1944-1962," Prairie Fortun, Vol. 30, No. 1 (Spring, 1995), pp. 87-105. Rands, Stan, "The CCF in Saskatchewanw in Donald C. Kerr ed. Western Canadian Poli tics: The Radical Tradi tion (Edmonton: NeWest Press, 1981), pp. 58-64. Swartz, Donald, The Politics of Reform: Public Health Insurance In Canada, International Journal of Health Services, Vol. 23, NO- 2(1993), pp. 219-238. Books Badgley , Robin F. and Wolfe, Samuel. Doctorsl Strike: Medical Care and Conflict in Saskatchewan. Toronto: Macmillan of Canada, 1967. Gray, G. Federalism and Health Policy. Toronto: University of Toronto Press, 1991. HOUBton, C. Stuart. R. G. Ferguson: Crusader against Tuberculosis. Toronto: Hannah Znstitute for the History of Medicine & Dundurn Press, 1991. Lipset, S. M. Agrarian Socialism: The Co -operative Commonweal th in Saskatchewan. Berkley: University of California, 1950. McLeod, Thomas H. and McLeod Ian. Tomy Douglas: The Road to Jerusalem. Edmonton: Hurtig Publishers, 1987. Naylor, C . David. Private Practise, Public Payment : Canadian Medicine and the Politics of Health Insurance, 1921-1966. Kingston and Montreal: McGill-Queens University Press, 1986. Rands, Stan. Privilege and Policy: A History of Comunity Clinics in Saskatchewan. Saskatoon: Community Health CO-operative Federation, 1995. Taylor, M. G . Heal th Insurance and Canadian Public Policy: The Sevan Decisions that Crea ted The Canadian Heal th Insurance System. Montreal: McGill-Queenfs University Press, 1978. Tollef son, E . A. Bit ter Medicine: The Saskatchewan Medicare Feud, Saskatoon: Modern Press, 1963. Unpublished nieses Mombourquette, Duane John. 'A Government and Health Care: The Co-operative Commonwealth Federation in Saskatchewan." Unpublished M. A. Thesis, University of Regina, 1990. Sherdahl, Raymond M. "The Saskatchewan General Election of 1944." Unpublished M. A. Thesis, University of Saskatchewan, 1963. Taylor, Malcolm G. "The Saskatchewan Hospital Services Plan: A Study in Compulsory Health Insurance." Unpublished Ph.D. Thesis, University of California, 1949. IMAGE EVALUATION TEST TARGET (QA-3) APPLIEO IMAGE.lnc -fi 1653 East Main Street , -. , Rochester, NY 14609 USA ,=.=-- Phone: 71 6M2-0300 --- Fax: 716nW-5989 O 1993. Applied Image. Inc.. All Rita Resefved